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PLATE  I. 


Buccal  Enanthem  in  Measles  (Koplik's  Spots.) 

(CourteBv  Dr.  John  Zahorsky.) 


THE 

J)ISEASES  OF  CHILDREN^ 


BY 

■4/ 

HENBY  ENOS  TULEY,  M.  D., 

LATE  PROFESSOR  OF  ORSTETRICS,  UXIVERSITY  OF  LOUISVILLE,  MEDICAL  DEPART- 
MENT;    VISITING     PHYSICIAN     MASONIC     WIDOWS'     AND     ORPHANS'     HOME, 
LOUISVILLE,    KY. ;     SECRETARY    OF    THE    AIISSISSIPPI    VALLEY    MEDICAL 
ASSOCIATION  :    EX-SECRETARY  AND  EX-CHAIRMAN  OF  THE  SECTION 
ON    DISEASES    OF     CHILDREN,     AMERICAN     MEDICAL    ASSOCIA- 
TION;   EX-PRESIDENT    AMERICAN    ASSOCIATION    MEDICAL 
MILK    COMMISSIONS,   ETC. 


With  One  Hundred  and  Six  Engravings 
AND  Three  Colored  Plates 


SEC50ND  REVISED  EDITION 


ST.  LOUIS 

C.  V.  MOSBY  COMPANY 
1913 


VMS/  oo 
\°\\3 


Copyright,  1913,  by  C.  V.  Mosby  Company 


Preaa  of 
C.   Y.   Mosby  Companu 
St.  Louis 


This  Book 

Is  Affectionately  Dedicated 

To 

MY  WIFE 

Whose  Life  has  been  a  Constant 

Inspiration    to    Higher    Endeavor 


PREFACE  TO  EIKST  EDITION. 

This  book  lias  been  written  not  for  the  specialist,  but  with 
the  needs  of  the  general  practitioner  and  student  in  view,  and 
the  diseases  of  children  have  been  described  as  they  are  seen 
by  the  busy  practitioner  in  his  daily  rounds. 

Believing  that  the  question  of  infant  feeding  is  one  of  the 
most  important  which  confronts  us,  much  more  space  has  been 
devoted  to  that  subject  than  is  given  other  important  ones.  We 
wish  to  interest  the  general  practitioner  in  milk,  its  care  and 
handling,  the  necessity  for  the  formation  of  certified  milk  com- 
missions, and  the  establishment  of  milk  depots  where  certified 
milk  may  be  placed  within  the  reach  of  the  poor. 

Each  disease  is  considered  in  a  methodical  manner.  Special 
attention  is  given  the  dietetic  and  hygienic  management,  and 
the  medicinal  treatment  is  considered  quite  fully,  with  the  repro- 
duction of  many  tried  formulae. 

Chapters  have  been  included  on  Diseases  of  the  Eye,  Ear, 
Nose  and  Throat,  and  the  Skin. 

Temperature  charts  have  been  reproduced  in  a  number  of 
places,  with  the  hope  that  this  valuable  clinical  aid  will  be 
more  often  employed  in  private  practice  than  it  is  at  present. 
A  world  of  valuable  data  and  statistics  is  lost  because  of  the 
practitioner's  failure  properly  to  record  bedside  notes  in  daily 
visits  to  the  private  patient.  We  would  encourage  this  feature 
of  the  work. 

Thanks  are  herewith  extended  to  Dr.  Wm.  Britt  Burns,  of 
IMemphis,  for  the  preparation  of  the  chapter  on  Malaria ;  to 
Dr.  Louis  Frank  and  Dr.  I.  Lederman  for  valuable  suggestions ; 
to  Mrs.  Mary  West  Fullenlove  for  painstaking  preparation  of 
the  manuscript,  and  to  the  publishers  for  their  many  courtesies 
during  the  publication  of  the  book. 

Henry  Enos  Tuley. 


PREFACE  TO  SECOND  EDITION. 

The  retirement  of  the  S6uthern  Medical  Publishing  Company 
from  the  field  of  book  publishing,  and  the  acquirement  of  the 
publication  rights  to  this  book  by  the  C.  V.  Mosby  Company, 
necessitated  the  entire  resetting  of  the  book  when  it  became 
apparent  a  second  edition  was  needed.  This  has  enabled  the 
author  to  rewrite  many  chapters  and  make  additions  throughout 
the  text  that  became  necessary  because  of  advancements  and 
discoveries  in  pediatrics  since  1909.  Advantage  has  been  taken 
also  of  this  opportunity  to  make  many  corrections  in  the  make-up 
of  the  book,  as  many  typographical  errors  crept  into  the  first 
edition. 

The  general  character  of  the  book  has  been  kept  the  same. 
The  needs  of  the  general  practitioner  and  student  have  been 
kept  in  the  front  always  and  as  far  as  possible  the  views  of  the 
authorities  in  diseases  of  children  have  been  given  as  well  as 
the  experience  and  observation  of  the  author. 

New  food  formulae  have  been  added  and  the  suggestive  stand- 
ards and  methods  for  the  production  of  Certified  milk  as 
adopted  by  the  American  Association  of  Medical  Milk  Commis- 
sions have  been  reproduced  in  full  in  the  appendix,  believing 
they  may  prove  of  value  to  many  who  may  contemplate  organ- 
izing a  medical  milk  commission,  or  help  to  make  better  com- 
missioners of  those  already  members  of  one. 

The  old  classification  of  the  diseases  of  the  gastro-intestinal 
tract  has  been  retained  with  the  full  knowledge  of  its  being  un- 
satisfactory, but  in  the  absence  of  a  better  one  it  was  thought 
best  to  adhere  to  the  old. 

A  number  of  new  illustrations  have  been  added  to  this  edi- 
tion, some  to  take  the  place  of  ones  which  had  been  lost,  others 
entirely  new.  We  are  indebted  to  several  authors  and  medical 
journals  for  the  use  of  special  cuts. 

Advantage  is  taken  of  this  opportunity  to  express  my  thanks 


PREFACE   TO   SECOND   EDITION. 

to  the  Publishers  for  their  many  courtesies,  to  my  secretary,  Miss 
Alice  Lee  Ford,  for  her  invaluable  assistance  in  the  preparation 
of  the  manuscript,  and  for  the  generous  reception  accorded  the 
first  edition,  which  we  bespeak  for  the  second  edition  as  well. 

Henry  Enos  Tuley. 
Aug.  1st,  1913. 


CONTENTS 

CHAPTER  I. 

PAGE 

Anatomy  of  Infants 17-24 

Circulation — Head — Ear — Nose — Spine — Thorax — Larynx — Trachea 
— Lungs — Thymus  Gland — Bronchial  Glands — Fetal  Heart — Stom- 
ach— Sigmoid  Flexure — Liver — Spleen — Kidneys — Testicles — Ute- 
rus— Ovaries — Heterotoxia. 

CHAPTER  II. 

The  New-bobn 25-35 

Asphyxia — Care  of  the  New-born — Preparation  for  the  Baby — 
Care  of  the  Napkins — ^The  Nursery. 

CHAPTER  III. 

Diseases  and  Injuries  of  the  New-born 36-52 

Caput  Succedaneum — Cephalhematoma — Umbilical  Hemorrhage — 
Granulating  Umbilicus — Hemorrhage — Umbilical  Hernia — Atelec- 
tasis— Icterus — Sepsis — Injuries — ^Mastitis — Starvation  Tempera- 
ture— Cerebral  Hemorrhage — Tetanus — Sclerema. 

CHAPTER  IV. 

Growth  and  Development 53-61 

Weight — Height — Progress — Dentition — Menstruation. 

CHAPTER  V. 

Methods  of  Examination 62-73 

Physical  Examination — Areas  of  Chest — History  Taking — Diagnos- 
tic  Signs — Temperature. 

CHAPTER  VL 

THERAPErTICS   OF    INFANCY    AND    CHILDHOOD 74-86 

Dosage — Methods  of  Calculation — Varieties  of  Medication — 'The 
Bath — Pack — Local  Application — Stomach  Washing — Colon  Irri- 
gation— Urine — Inunction. 

CHAPTER  VII. 

Infant  Feeding     . 87-151 

Infant  Feeding — Breast  Feeding — Nursing  Mother — Breast  Milk — 
Wet    Nurse — Weaning — Combined    Feeding — Artificial    Feeding — 


CONTENTS. 

PAGE 

Cow's  Milk — Certified  Milk — Foreign  Matter  in  Milk — Changes  in 
Milk  from  Bacteria — Market  Milk — Tuberculosis  and  Milk — Epi- 
demics due  to  Milk — Care  of  Milk  in  Home — Morbidity  and  Mor- 
tality Statistics  Influenced  by  Milk — Sterilization  and  Pasteur- 
ization— Composition  of  Milk — Inspection  of  Dairies — Care  of 
Bottle  and  Nipples — Modified  Milk — Top  Milk — Condensed  Milk — 
Whey — Calories — Artificial  Foods — Diet  after  First  Year — Gavage 
— Rectal   Feeding. 

CHAPTER  VIII. 

Diseases  of  the  Nose,  Throat  and  Pharynx 152-171 

Acute  Rhinitis — Chronic  Rhinitis — Atrophic  Khinitis — Epistaxis — 
Nasal  Polypi — Diseases  of  the  Tonsils — Acute  Catarrhal  Tonsillitis 
— Follicular  Tonsillitis — Chronically  Enlarged  Tonsils — Uvulitis — 
Peritonsiliar  Abscess — Retropharyngeal  Abscess — Adenoids — Dis- 
eases of  Larynx — Acute  Catarrhal  Laryngitis — Congenital  Laryn- 
geal Stridor. 

CHAPTER  IX. 

Diseases  of  the  Ear 172-18G 

Diseases  of  the  External  Auditory  Canal — Furunculosis — Impacted 
Wax — The  Middle  Ear — Acute  Tubo-tympanic  Catarrh — Acute 
Catarrhal  Otitis  Media — Acute  Suppurative  Otitis  Media — ^Mastoi- 
ditis. 

CHAPTER  X. 

Diseases  of  the  Eye 187-190 

Eye  Strain — Blepharitis — Herdeolum — Conjunctivitis — Trachoma — 
Grandular  Conjunctivitis — Vernal  Catarrh  of  the  Conjunctiva — 
Diphtheritic  Conjunctivitis — Phlyctenular  Conjunctivitis — Oph- 
thalmia Neonatorum — Diseases  of  the  Cornea — Pterygium — Phylc- 
tenular  Keratitis — Intestitial  Keratitis. 

CHAPTER  XL 

Diseases  of  the  Respiratory  Tract 200-232 

Foreign  Bodies  in  Bronchial  Tubes — Asthma — Atelectasis — Acute 
Catarrhal  Bronchitis — Chronic  Catarrhal  Bronchitis — Emphysema 
— Broncho-pneumonia — Lobar  Pneumonia — Pleurisy — Empyema — 
Gangrene  of  Lung. 

CHAPTER  XII. 

Diseases    of    the    Digestive    System 2.33-286 

Diseases  of  the  Lips — Ulcerations  at  Anglo  of  Mouth — llt-rpes — 
Diseases  of  the  Tongue — ^Diseases  of  the  Mouth — Bednar's  A](Iitlia! 


CONTENTS. 

PAGE 
— stomatitis — Tlirusli — Ranula — Tongue-tie — Riga's  Disease — Al- 
veolar Abscess — Fistula  of  Neck — Acute  Esophagitis — Stenosis  of 
Pylorus — Diseases  of  Stomach  and  Intestines — ^Tlie  Feces — Gastric 
Disorders — Acute  Gastric  Indigestion — Acute  Gastritis — Chronic 
Gastritis — Gastric  Dilatation — Cyclic  Vomiting — Colic — Gastralgia 
— Acute  Gastro-enteric  Infection — Cholera  Infantum — Acute  Enter- 
colitis — Chronic  Entercolitis — Constipation — Dilatation  of  Colon. 

CHAPTER  XIII. 

Intestinal  Parasites 287-295 

Oxyuris  vermicularis — Ascaris  lumbricoides — Ankylostomum  duo- 
denale — Tenia   solium — Tenia   Medicanellata. 

CHAPTER  XIV. 

Surgical  Conditions  of  the  Intestine 296-506 

Appendicitis — Intussusception. 

CHAPTER  XV 

General  Diseases "  .      .  307-367 

Typhoid  Fever — Rheumatism — Diabetes  Mellitus — Tuberculosis — 
Tubercular  Meningitis — Tubercular  Peritonitis — Pellagra — Malaria 
— Syphilis. 

CHAPTER  XVI. 

Contagious  Disease:s 368-429 

Measles — German  Measles — Scarlatina — ^Varicella — ^\^accination — 
Vaccinia — Variola — Pertussis — Parotitis^— LaGrippe — Diphtheria — 
Intubation — Intubation  and  Quarantine  in  Contagious  Diseases. 

CHAPTER  XVII. 

Diseases  of  the  Circulatory  System 430-450 

The  Heart — Congenital  Heart  Disease — Pericarditis — Pericarditis 
with  Effusion — C'hronic  Pericarditis — Pyopericardium — Endocar- 
ditis— Malignant  Endocarditis — Chronic  Endocarditis — Mitral 
Regurgitation — Mitral  Stenosis — Aortic  Regurgitation — Aortic 
Stenosis — Tricuspid  Regurgitation — Tricuspid  Stenosis — Treatment 
of  Valvular  Lesions — Functional  Disorders  of  Heart — Bradycardia 
— Tachycardia — Acute  Myocarditis. 

CHAPTER  XVIII. 

Diseases  of  the  Blood 451-468 

The  Blood  of  Infancy  and  Childhood — Anemia — Pernicious  Anemia 
— Chlorosis — Lympiiatic  Leukemia — Pseudoleukemia — Pseudoleuke- 
mia  of   Infants — Purpura — Hemophilia. 


CONTENTS. 

chaptp:r  XIX 

PACK 
DiSJCASES   OF   THK  LYMPHATIC   GlANDS 46!>-475 

The  Thymus  Gland — Acute  Adenitis — Chronic  Adonitis — Addison's 
Disease — Cretinism. 

CHAPTER  XX. 

Diseases  of  the  Genito-urinary  System 476-500 

The  Urine — Albuminuria — Pyelitis — Renal  Calculus — Perinephritis 
— Acute  Parenchymatous  Nephritis — Chronic  Nephritis — Chronic 
Interstitial  Nephritis — Tumors  of  the  Kidnej's — Hydronephrosis — 
Enuresis — Phimosis — Paraphimosis — Hydrocele — Balanitis  —  Ure- 
thritis— Vulvo-vaginitis — Cystitis — Undescended  Testicle. 

CHAPTER  XXI. 

Nutritional  Disorders 501-512 

Athrepsia — Scorbutus — Rachitis. 

CHAPTER  XXII. 

Diseases  of  the  Nervous  System 513-574 

General  Considerations — Diagnostic  Methods — Convulsions — Chorea 
— Hysteria — Epilepsy — Disorders  of  Sleep — Multiple  Neuritis — 
Facial  Palsy — Obstetrical  Paralysis — Infantile  Paralysis — Acute 
Myelitis — Pott's  Disease — Tumors  of  the  Spinal  Cord — Syphilis  of 
the  Cord — Disseminated  Sclerosis — Hereditary  Ataxia — Hereditary 
Spastic  Paralysis — Progressive  Muscular  Dystrophy — Meningitis 
— Epidemic  Cerebro — Spinal  Meningitis — Acute  Encephalitis — Hy- 
drocephalus— Chronic  Hydrocephalus — Cerebral  Palsies — Tumors  of 
Brain  and  Meninges — Abscess  of  Brain — Intracranial  Hemorrhage. 

CHAPTER  XXIII. 

Diseases  of  the  Skin 575-597 

Intertrigo — Sudamina — Pediculosis — Scabies  —  Ringworm  —  Tinea 
Favosa  —  Impetigo  Contagiosa  —  Pemphigus — Eczema — Herpes — 
Pruritus — Urticaria — Psoriasis. 

APPENDIX. 

Milk  Modifications — Babies'  Milk  Fund  Association  Brochure — 
Refrigerator — Methods  and  Standards  for  Production  and  Distri- 
bntion  of  Certified  Milk. 


ILLUSTRATIONS 

Plate  I.     Buccal  Enantliem  in  Measles  (Koplik's  Spots)      .     Frontispiece 

Plate  II.     Life-Cycle  of  Plasmodium  Vivax   ....     Facing  page  3T0 

Plato  III.     Tonsillar  Diphtheria — Follicular  Tonsillitis    .   Facing  page  410 

FIGURE  PAGE 

1.  Capacity  of  infant's  stomach 21 

2.  Size  of  infant's  stomach,  three  months 22 

3.  Size  of   infant's   stomach,   six  months 22 

4.  Dissection  of  still-horn  child 23 

5.  Funis    Band    Applicator 29 

6.  Umhilical  granulation  removed  by  ligature  six  weeks  after  birth  38 

7.  Adliesive  strap  for  umbilical  hernia 43 

8.  Starvation    temperature    chart 48 

9.  Hammock  scale      . 53 

10.  Nursery  scales 64 

11.  Temporary  and  permanent  teeth 58 

12.  Showing  axillary  and   infra-axillary  regions 62 

13.  Anterior  regions  of  the  chest 63 

14.  Posterior  regions  of  the  chest 63 

15.  Position  for  taking  rectal  temperature     .' 65 

16.  Examination  of  throat  by  direct  illumination 67 

17.  Tongue   depressor  handle  with   removable  vooden  depressors     .  68 
li8.     Ear  specula 68 

19.  Bowles  stethoscope  with  small  chest  piece     . 70 

20.  Position   for   auscultation   of  back 71 

21.  Auscultation  of  chest 72 

22.  Stanton's  percussion  hammer 73 

23.  Rubber  bulb  syringe 75 

24.  Collapsible   rubber  bath   tub 78 

25.  Glass  syringe 82 

20.     Apparatus  for  stomach  washing 83 

27.  Colon  irrigation 84 

28.  Holt's  milk  set      . 91 

29.  Certified  Dairy  No.  2 .  101 


IUjUSTRATIONS. 

figure  page 

29a.  Certified  Dairy  No.  2 102 

30.  Certified  milk  bottle 104 

31.  Certified  milk  in  special  glasses 104 

32.  Gurler  milk  pail lOG 

33.  Hooded   milk  pail 106 

34.  Certified  milk  shipping  cases 100 

34a.  Box  used  for  collecting  samples  of  milk  in  original  bottles   .      .    107 
34b.  Box  used  in  collecting  samples  of  milk  in  biilk 107 

35.  Sample  of  unsuspected  but  dangerous  tubercular  cow     .      .      .      .110 

36.  Castle  Pasteurizer 116 

37.  Hygeia  Pasteurizer 116 

38.  Babcock   butter   fat   test 129 

39.  Chapin   cream   dipper 130 

40.  Cross-section  of  human  tonsil,  age  11  years 156 

41.  Osteomyelitis  following  streptococcic  infection  from  tonsillitis   .    160 

42.  Tonsillotome 162 

43.  Croup  kettle 170 

44.  Instrument  for  paracentesis  of  the  drum 176 

45.  Otitis  media  both  ears,  temperature  chart 180 

46.  Roller  forceps  for  trachoma 191 

47.  Five-cent  piece  in  esophagus 201 

48.  Vaporizer 207 

49.  Lobar  pneumonia;  crisis  seventh  day.     (Temperature  chart)     ..   219 

50.  Mucosa  normal   colon 283 

51.  Mucosa  giant  colon 284 

52.  Congenital  idiopathic  dilatation  of  the  colon 285 

53.  Side  view,  same  patient  as  above 285 

54.  Eggs  of  oxyuris  vermicularis 288 

55.  Eggs  of  ascaris  lumbricoides 290 

56.  Head  of  tenia  solium 293 

57.  Head   of   tenia   solium 293 

58.  Head  of  tenia  saginata 293 

59.  Typhoid  fever  with  reinfection,  temperature.      (Chart)      .      .      .   310 

60.  Typhoid  fever;   hemorrhage;   perforation.      (Temperature  chart)    312 

61.  Temperature  chart  for  81  days  in  child  witii  general  tuberculosis  333 

62.  Same  as  above 333 

63.  Pellagrous  dermatitis 344 


ILIiUSTBATIONS. 

FIGURE  PAGE 

C4.     Anopheles  Crucians,  Female  mosquito,  greatly  enlarged     .      .      .  348 

05.     Anopheles   punctipennis.    Female   mosquito,   greatly   enlarged     .  348 
()G.     Anopheles  quadrimaculatus.     Female  mosquito,  greatly  enlarged  348 

67.  Anopheles  mosquito  at  rest 348 

68.  Common  mosquito  at  rest 348 

69.  Malarial  hemoglobinuria,  temperature.      (Chart) 358 

70.  Measles,  temperature.      (Chart) 370 

71.  Measles  with  complicating  pneumonia,  temperature.      (Chart)    .  372 

72.  German  measles,  temperature.      (Chart) 377 

73.  The  whooping-cough  belt 404 

74.  Rear  view   of  the  whooping-cough  belt   applied 404 

75.  Laryngeal     and    nasal     diphtheria;     intubation.      (Temperature 

chart) .•    .      .      .  414 

76.  Diphtheritic  casts  of  trachea  and  bronchi 416 

77.  O'Dwyer    Intubation    Tubes 423 

78.  Position  for  intubation.     First  step     .      .' 425 

79.  Intubation.     Second   step.     Introducer   about   to   be   removed     .  425 

80.  Position   for   feeding   child  wearing  intubation  tube   ....  426 

81.  Tallquist    hemoglobin    scale 452 

82.  Dare's  hemoglobinometer 452 

83.  Locating  the  inter-vertebral  space  for  lumbar  puncture     .      .      .  517 

84.  Lumbar  puncture.     Nurse  holding  sterile  bottle  to  catch  fluid     .  517 

85.  X-ray  of  Pott's  disease 546 

86.  Typical    attitude   assumed   by   patient   with   pseudohypertrophic 

muscular   paralysis 554 

87.  Same  as  Fig.  86 554 

88.  Same  as  Fig.  86 554 

89.  Typical  muscular  enlargement 555 

90.  Pure  culture  of  meningococcus,  36  hours  old 557 

91.  92,  93,  94.     Series  of  microphotographs  illustrating  the  change  in 

the  cerebrospinal  fluid  under  the  influence  of  serum  treatment 

with  improvement 558 

95.  Boy  of  eleven,  ill  forty-eight  hours  with  epidemic  meningitis     .  500 

96.  Boy  of  thirteen  lying  in  the  usual  position  of  those  ill  with  epi- 

demic meningitis 560 

97.  Pliotograph  of  boy  of  ten  and  one-half  years,  taken  five  days  after 

tiie  onset  of  epidemic  meningitis 560 

98.  Hydrocephalus.     Child  six  years  old ■ .  566 


ILLUSTRATIONS. 

FIGUBE  PAGE 

99.     Side  view  same  child  as  in  Fig.  98 566 

100.  Pemphigus  vulgaris  acuta 588 

101.  Pemphigus,  temperature.      (Chart) 589 

102.  Westcott's  milk  modification  chart 601 

103.  Haas'  Materna 603 

104.  Deming  Modifier • 603 

105.  Hess    home-made    refrigerator.     Horizontal   section      .      .      .      .631 

106.  Hess  home-made   refrigerator.     Vertical  section 631 


THE  DISEASES  OF  CHILDREN 

CHAPTER  I. 

ANATOMY  OF  INFANTS. 

The  infant's  anatomy  differs  from  that  of  the  adult  in  many 
essential  points.  The  chief  of  these  is  the  change  which  takes 
place  in  the  circulation  immediately  after  birth.  These  may 
be  named  as  follows,  probably  in  the  order  of  their  happening: 
Opening  of  the  pulmonary  arteries;  closure  of  the  foramen 
ovale,  complete  about  the  tenth  day;  disappearance  of  the  Eu- 
stachian valve;  obliteration  of  the  ductus  arteriosus,  ductus 
venosus  and  the  hypogastric  arteries,  the  latter  remaining  pervi- 
ous from  the  internal  iliac  arteries  to  the  bladder,  known  after 
birth  as  the  superior  vesical  arteries.  The  umbilical  vein  and 
the  ductus  venosus  close  about  the  fifth  day,  the  latter  persist- 
ing in  its  impervious  state  as  the  round  ligament  of  the  liver. 
With  the  tying  of  the  cord  the  hypogastric  arteries  and  the  ves- 
sels in  the  cord  are  obliterated. 

The  child's  head  is  very  soft  and  compressible,  the  bones  are 
ununited  and  separated  by  sutures;  where  the  sutures  coalesce 
are  the  anterior  and  posterior  foiitanelles.  The  anterior  fon- 
tanelle,  at  the  anterior  superior  end  of  the  parietal  bones  is 
larger  than  the  posterior  and  quadrilateral  in  shape.  It  closes 
during  the  second  year.  The  posterior  fontanelle  at  the  poste- 
rior inferior  ends  of  the  parietal  bones  is  triangular  in  shape 
and  smaller.     It  closes  by  the  end  of  the  first  year. 

As  a  result  of  moulding  during  birth  the  head  in  normal 
casas  is  much  elongated  from  the  chin  to  the  occiput,  and  if  a 
large  caput  succedanetim  is  present  it  is  still  further  misshapen. 
Its  normal  contour  is  restored  in  a  few  days.  The  scalp  is  quite 
mobile,  owing  to  its  loose  attachment  to  the  aponeurosis.  The 
frontal  hone  is  divided  into  two  equal  parts  by  the  frontal  suture. 

17 


18  THE   DISEASES   OF    CHILDREN. 

The  sphenoidal  and  temporal  bones  consist  of  three  separate 
pieces  each.  The  mastoid  cells  are  not  present.  The  inferior 
maxilla  is  divided  into  two  equal  portions  united  by  fibrous  tis- 
sue at  the  chin. 

The  infant's  ear  differs  greatly  from  the  adult's.  At  birth 
the  axis  of  the  meatus  is  directed  upward,  the  canal  being 
smaller  at  the  inner  end.  The  auricle  is  pulled  downward  to 
obtain  a  view  of  the  tj'rapanum. 

The  Eustachian  tubes  in  the  infant  are  about  half  the  length 
of  the  adult's;  they  are  straight,  and  nearlj^  horizontal,  and  the 
pharyngeal  opening  is  about  on  a  level  with  the  hard  palate, 
and  smaller,  relatively,  than  in  the  adult. 

The  nose  is  small  in  infancy  and  the  respiratory  space  in 
the  nares  very  limited.  The  nasopliarynx  is  quite  deep.  It  is 
vascular  and  rich  in  lymphoid  tissue.  The  presence  of  this 
lymphoid  tissue  is  a  menace  to  infants  as  it  becomes  easily  in- 
flamed and  swollen,  obstructing  the  respiratory  area. 

The  spine  is  very  flexible,  the  bones  at  birth  are  mostly  carti- 
laginous, the  nuclei  of  ossification  being  present.  Spina  bifida 
results  from  a  failure  of  the  lamina&  to  unite  allowing  a  pro- 
trusion of  the  membranes  of  the  cord  or  filaments  of  the  cord 
itself.  The  upper  extremities  are  much  better  developed  at  birth 
than  the  lower,  the  fetal  circulation  providing  a  venous  blood 
to  the  lower  extremities. 

The  clavicle  is  one  of  the  first  bones  to  ossify.  The  ossifica- 
tion of  the  long  bones  begins  in  the  center  of  tlie  diaphysis.  The 
bones  of  the  thorax  are  mostly  cartilaginous,  hence,  the  elasticity 
of  this  portion  of  the  body.  Several  centers  of  ossification  are 
present  in  the  sternum.  The  Jari/nx  is  higher  than  in  the  adult, 
being  about  on  the  level  with  the  axis,  and  a  view  of  the  epi- 
glottis and  vocal  cords  can  frequently  be  had  without  the  aid  of 
a  mirror. 

The  trachea  divides  at  about  the  third  lumbar  vertebra.  The 
opening  into  the  right  lung  is  larger  than  the  left,  the  right 
bronchus  not  having  quite  so  wide  an  angle. 

The  lungs  at  birth  are  small  and  the  air  vesicles  entirely  col- 
lapsed. On  removing  the  anterior  chest  wall  of  a  still-bom 
child  the  lungs  do  not  fill  the  tlioracic  caAdty  and  the  heart  is 


ANATOMY   OF   INFANTS.  19 

found  uncovered,  the  thymus  gland  extending  usually  below  the 
base  of  the  heart.  As  a  result  of  the  first  deep  inspiration  the 
air  vesicles  are  dilated,  the  lungs  expand,  fill  the  cavity  and 
cover  the  heart.  The  division  of  the  right  lung  into  three  lobes 
is  quite  marked  in  the  infant,  with  a  deep  fissure  especially 
posteriorly  between  each.  The  lower  border  of  the  right  lung 
posteriorly,  reaches  the  tenth  rib  on  the  right  side,  and  to  the 
eleventh  rib  on  the  left  side. 

The  thymus  gland  is  an  organ  but  little  understood.  It  is 
present  in  the  new-born,  often  being  relatively  of  great  size, 
gradually  growing  smaller  after  birth.  It  may  extend  as  low 
as  the  fourth  rib,  and  above  the  suprasternal  notch.  It  has  two 
lobes,  and  may  measure  23/^  by  11/^  inches.  Its  undue  develop- 
ment has  been  supposed  to  be  the  cause  of  some  otherwise  unex- 
plained cases  of  sudden  death. 

The  hro-nchial  glands  are  located  around  the  trachea  in  its 
lower  portion  and  extend  around  the  bronchi  at  their  bifurca- 
tion. These  are  normally  quite  small,  but  as  a  result  of  an 
infection  may  assume  quite  a  large  size. 

The  fetal  heart  differs  from  that  of  the  new-born  in  the 
presence  of  the  interauricular  opening,  the  foramen  ovale,  and 
the  Eustachian  valve,  which  is  supposed  to  guide  the  blood  from 
the  inferior  vena  cava  through  the  right  auricle  into  the  left 
auricle.  The  cavities  of  the  right  side  are  larger  than  the  left, 
the  heart  weighing  about  two-thirds  of  an  ounce,  at  birth.  With 
the  change  in  the  circulation  after  birth  the  heart  assumes 
more  the  adult  type,  the  left  side  l)ecojning  larger.  The  apex 
beat  is  felt  about  the  fourth  interspace  farther  to  the  left  than 
in  the  adult. 

The  fetal  circulation  is  as  follows:  Leaving  the  placenta  the 
blood  flows  through  the  umbilical  vein  to  the  umbilical  open- 
ing, ascending  to  the  under  surface  of  the  liver  from  there 
through  the  ductus  venosus,  a  fetal  structure,  to  the  inferior 
or  ascending  vena  cava.  From  the  inferior  vena  cava  the  stream 
goes  into  the  right  auricle  guided  by  the  Eustachian  valve 
through  the  foramen  ovale  into  the  left  auricle.  From  the  left 
auricle  through  the  mitral  orifice  to  the  left  ventricle ;  from 
the  left  ventricle  to  the  ascending  aorta,  through  the  larger  ves- 


20  THE   DISEASES  OF    CHILDREN. 

sels  of  the  neck  to  the  brain  and  upper  extremities.  The  blood 
returns,  via  the  superior  or  descending  vena  cava,  to  the  right 
auricle,  being  largely  venous  in  character ;  from  the  right  auricle 
to  the  right  ventricle,  the  pulmonary  arteries  being  impervious, 
the  blood  is  carried  through  the  ductus  arteriosus,  a  fetal  struc- 
ture, to  the  descending  aorta.  Through  the  descending  aorta 
the  blood  flows  as  far  as  the  iliac  vessels,  a  portion  of  it  going 
through  the  external  iliac  to  the  lower  extremities,  the  rest  of 
the  blood  going  through  the  hypogastric  arteries,  branches 
of  the  internal  iliacs,  over  the  summit  of  the  bladder  and  under 
the  anterior  abdominal  wall  to  the  abdominal  opening  where 
these  vessels  become  the  umbilical  arteries. 

The  umbilical  opening  may  be  patulous  at  birth  and  allow 
a  protrusion  through  into  the  cord  of  a  loop  of  the  intestine,  or 
there  may  be  a  separation  of  the  umbilical  ring  after  the  stump 
of  the  cord  falls  off  allowing  a  protrusion  of  intestine  and  the 
formation  of  an  umhilical  hernia.  There  have  been  a  few  cases 
reported  where  a  coil  of  intestine  had  been  included  in  a  ligature 
which  encircled  the  cord  to  tie  the  umbilical  vessels. 

The  stomach  at  birth  is  more  like  the  dilated  end  of  the  esoph- 
agus than  a  separate  organ  itself,  due  to  the  pyloric  end  being 
pushed  downward  by  the  left  lobe  of  the  liver,  causing  it  to  as- 
sume more  of  the  upright  position.  Regurgitation  of  its  con- 
tents is  very  easy  because  of  this.  The  stomach  at  birth  will 
hold  about  1  ounce.  The  cardiac  opening  is  located  about  oppo- 
site the  first  dorsal  vertebra,  the  principal  difference  in  the  intes- 
tine is  the  relatively  large  size  and  length  of  the  sigmoid  flexure 
of  the  colon. 

The  sigmoid  flexure  at  birth  is  about  as  long  as  the  colon 
itself,  the  sigmoid  extending  frequently  much  beyond  the  median 
line.  Owing  to  the  shallowness  of  the  pelvis  most  of  the  sig- 
moid is  in  the  abdominal  cavity. 

The  liver  is  one  of  the  heaviest  organs  in  the  body  at  birth, 
its  relative  weight  to  that  of  the  body  being  1  to  18.  Its  growth 
and  development  are  due  to  its  receiving  first  the  pure  arterial 
blood  as  it  comes  from  the  placenta.  The  left  lobe  may  extend 
much  beyond  the  median  line. 

The  spleen  is  small  at  birth,  lying  usually  under  the  ninth 


ANATOMY   OF   INFANTS. 


21 


and  tenth  ribs,  and  cannot  be  felt  upon  palpation  unless  en- 
larged. The  kidneys  are  about  on  a  line  with  each  other.  They 
are  distinctly  lobulated  and  may  be  joined,  forming  a  horseshoe 
kidney.  On  section  a  number  of  uric  acid  infarcts  may  be 
found. 


Fig.    1. — Capacity    of    infant's    stomach    (Kelley). 

The  suprarenal  glands  are  relatively  larger  at  birth  than  in 
the  adult.  They  are  highly  vascular  and  may  be  the  site  of 
heinori'hage.  (See  report  of  ease  on  page  40.)  The  male  ure- 
thra will  average  two  inches  in  length  and  shows  quite  a  distinct 
constriction  at  the  meatus.     The  fossa  navicularis  is  relatively 


22 


THE   DISEASES   OF    CHILDREN, 


Vis-    2. — Size    of    infant's    stomach    three    months    (Kelley). 


Fig.    3 — Size   of   infant's   stomach   six   months    (Kelley). 


ANATOMY   OF    INFANTS. 


23 


larger  than  the  rest  of  the  urethra  and  may  be  the  site  of  the 
formation  of  a  concretion  or  stone  in  late  infancy. 

The  corona  glandis  is  tightly  covered  by  the  prepuce,  fre- 
quently adherent,  with  an  accumulation  of  smegma  behind  the 
corona  glandis. 


^iij^^ 

-    m^^^^^ 

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^^^^Hr,  iiMft'     -^     "                       v^ 

^^P       %-                 Jr    ''^tfttf^B^^^^^ 

^c  .^ 

^^*J 

'mKmm^^l 

^H^  ' 

■li.         .--#1^  •^-»^  .ml 

n 

\ 

--^HgHHK^^r                '<«F. 

Fig.     t. — Disscftion    of    still-bdiii    cliild.      Note    the    course    of    the    sigmoid,     also    tlic 
rehitively    large   size   of   the   liver. 

The  testicles  in  the  embryo  are  found  in  the  abdominal  cavity, 
below  the  kidneys,  in  the  lumbar  region.  At  about  the  eighth 
month  they  descend  and  pass  out  into  the  scrotum  through  the 
inguinal  canals. 

A  child  whose  testicles  are  retained  within  the  canal  or  cavity 


24  THE   DISEASES   OF    CHILDREN, 

is  called  a  cryptorchid,  if  only  one  has  descended,  a  monorchid. 

The  uterus  at  birth  is  small,  about  1  inch  in  length;  the 
ovaries  are  found  in  the  lumbar  region  in  intrauterine  life,  and 
at  birth  are  as  low  as  the  brim  of  the  pelvis.  It  is  estimated 
that  upwards  of  75,000  ova  are  in  each  ovary  at  birth. 

The  relative  weight  of  the  hrain  at  birth  to  the  body  is  1  to  8. 
The  color  is  quite  pale  and  contains  a  larger  percentage  of 
water  than  the  adult  brain. 

HETEROTAXIA. 

Irregular  malpositions  of  viscera  are  occasionally  observed  in 
routine  practice.  These  abnormalities  have  been  exhaustively 
studied  by  Ballantj'ne,  Osier,  Arneill,  Koyer  and  Wilson. 

The  usual  form  observed  is  a  complete  transposition,  of  either 
the  thoracic  or  abdominal  organs  or  both. 

Among  the  remarkable  cases  on  record  (Arneill  ^  reporting 
300  collected  from  the  literature)  are  maintenance  of  fetal  vascu- 
lar conditions  after  birth ;  lobulated  spleen  or  multiple  spleens ; 
one  kidney;  transposition  of  the  cavities  of  the  heart;  of  the 
lungs,  liver  and  spleen. 

The  fetal  condition  of  the  heart  can  be  made  out  by  physical 
examination.  The  other  transpositions  may  not  be  suspected 
until  found  postmortem,  and  unless  the  heart  is  involved 
the  child  may  reach  adult  life ;  with  involvement  of  the  heart 
these  children  rarely  reach  puberty. 

1  American   Journal   Medical   Sciences,    November,    1902. 


CHAPTER  II. 
THE  NEW-BORN. 

As  soon  as  the  child's  head  is  born,  and  before  the  birth  of 
the  body,  feeble  attempts  are  made  at  inspiration.  At  this  time 
the  mouth  should  be  wiped  out  promptly  and  freed  of  the  mucus 
and  fluid  which  it  contains  in  order  to  prevent  its  being  aspi- 
rated in  the  bronchial  tubes,  with  the  first  deep  inspiration. 

Reacting  to  the  stimulus  of  the  air  upon  the  skin,  the  first 
inspiration  is  taken  and  the  air  vesicles  are  dilated.  The  skin 
quickly  changes  from  a  pallid  or  bluish  color  to  the  normal  red, 
and  the  child  cries  lustily.  The  respirations  at  first  are  shal- 
low, often  slightly  irregular,  and  they  are  of  the  abdominal 
type.  The  chest  soon  becomes  fully  expanded  and  the  number 
of  respirations  which  at  first  was  60  or  70  to  the  minute  will 
average  about  40  at  the  end  of  the  first  hour. 

ASPHYXIA. 

Where  insufficient  air  has  entered  the  lungs  of  the  new-born 
to  dilate  the  air  vesicles  the  child  is  still-horn.  When  some  air 
does  enter  the  lungs  and  for  any  reason  there  is  an  interference 
with  the  proper  exchange  between  oxygen  and  carbon  dioxide, 
the  condition  is  called  asphyxia. 

Forms. — Asphyxia  may  be  intrauterine.  This  form  is  caused 
by  any  interference  with  the  uteroplacental  circulation ;  as  a 
premature  or  accidental  separation  of  a  portion  of  the  placenta; 
knots  in  the  cord,  too  tight  loop  or  loops  of  the  cord  around  the 
child's  neck;  long-continued  labor  from  any  cause;  compression 
of  the  cord  by  the  after-coming  head ;  compression  of  the  fetal 
brain  by  forceps  operation ;  death  of  the  mother  and  prema- 
turity. 

Intrauterine  asphyxia  may  be  foretold  by  the  premature 
e.S(;ape  of  meconium  in  vertex  presentations  and  by  an  inter- 
ruption in  the  beat  of  the  fetal  heart,  either  very  rapid  or  very 
slow  heart  sounds.     In  interference  with  placental  respiration, 

25 


26  THE   DISEASES   OP    CHILDREN. 

the  blood  of  the  fetus  is  surcharged  with  carbon  dioxide,  an 
increased  intestinal  peristalsis  and  a  relaxation  of  the  sphincter 
occurs,  allowing  escape  of  the  meconium.  In  breech  presenta- 
tion, the  escape  of  meconium  is  from  pressure  causes  entirely, 
and  is  of  no  significance. 

If  premature  respiration  occurs  before  the  birth  of  tlie  head, 
liquor  amnii  and  mucus  may  be  aspirated,  which  will  mechan- 
ically act  as  a  cause  of  asphyxia. 

The  persistence  of  the  intrauterine  apnea  after  birth  con- 
stitutes the  postnatal  form  of  asphyxia.  The  chief  cause  of 
this  form  is  an  injury  to  the  respiratory  centers  by  prolonged 
labor;  prematurity,  the  thin  chest  walls  making  it  impossible 
for  the  lungs  to  dilate  because  of  external  atmospheric  pressure, 
a  general  atelectasis  following  in  these  cases. 

Symptoms. — In  the  intrauterine  form  of  asphyxia,  the  child 
is  born  limp  and  the  skin  is  pale  or  blue.  Two  forms  are  gen- 
erally referred  to,  asphyxia  livida  and  asphyxia  pallida,  the 
latter  being  the  most  profound.  In  the  mild  cases  there  is  a 
very  feeble  intake  of  air,  noted  by  slight  movement  of  the  dia- 
phragm, strong  umbilical  pulsation  and  muscular  action  of  the 
face  and  nose.  If  improvement  follows,  the  respirations  will  be- 
come more  regular  and  less  spasmodic,  the  color  will  improve 
and  the  child  will  utter  a  feeble  whine  or  cry. 

Prognosis. — The  prognosis  in  all  cases  of  asphyxia  is  very 
grave.  Atelectasis  is  always  to  be  feared.  If  the  child  does  not 
nurse  well,  has  a  persistent  subnormal  temperature  and  pro- 
gressive and  rapid  loss  in  weight,  the  prognosis  is  more  grave. 
As  long  as  there  are  any  heart  beats  to  be  heard  one  should 
persist  in  efforts  at  resuscitation  by  artificial  respiration. 

Treatment. — Prophylaxis  of  asphyxia  should  be  lx)rne  in  mind 
in  every  ca.se  of  lal)or.  Intelligent  interference  in  cases  of  pro- 
longed labor  with  the  fetal  heart  as  a  guide  is  always  indicated, 
and  will  prevent  many  cases  of  asphyxia.  The  mouth  and  nose 
should  be  carefully  cleansed  of  mucus  and  the  face  not  allowed 
to  remain  in  the  discharges  upon  the  bed  or  table,  if  the  delivery 
is  accomplished  in  the  dorsal  position.  A  basin  or  tub  which 
will  hold  enough  Avater  to  completely  cover  the  child's  body, 
should  be  part  of  the  equipment  of  every  delivery  room,  as  fre- 


THE   NEW-BORN.  27 

queiitly  respiration  will  be  stimulated  by  immersing  the  child 
in  water  at  a  temperature  of  105°  or  110°  F.,  and  occasion- 
ally allowing  a  small  quantity  of  cold  water  to  trickle  over  its 
chest  or  plunging  it  for  a  second  in  cold  water.  If  this  fails, 
resort  should  be  had  at  once  to  the  use  of  one  of  the  methods  of 
artificial  respiration. 

A  soft  catheter  may  be  introduced  into  the  trachea  and  mucus 
aspirated  through  it,  if  the  obstruction  seems  to  be  of  that  na- 
ture. The  suspension  of  the  child  by  its  feet,  and  flagellation 
of  back  and  buttocks  serve  to  allow  drainage  from  the  lungs, 
stimulates  the  medulla  by  rush  of  blood  by  gravity  and  by 
reflex  action  through  the  skin,  aids  in  respiration.  It  should 
be  then  plunged  into  the  hot  bath  at  once. 

The  Byrd-Dew  method  can  be  used  to  advantage  with  the 
child  immersed  in  the  water.  This  method  consists  in  holding 
the  child  upon  its  back  in  the  palms  of  the  hands,  the  head 
supported  by  one  hand.  Expiration  is  produced  by  bringing 
the  pelvis  toward  the  chest,  arching  the  spine  backward  and 
compressing  the  lungs.  Inspiration  is  produced  by  raising  the 
ulnar  sides  of  the  hands,  thus  arching  the  spine  forward.  At 
the  same  time  the  head  is  allowed  to  fall  back,  thus  straighten- 
ing the  trachea  and  aiding  inspiration. 

With  all  the  methods  of  artificial  respiration,  mouth  to  mouth 
imufflation  is  of  benefit  as  it  dislodges  mucus  concealed  in  the 
nasopharynx  and  forcibly  dilates  the  air  vesicles.  The  child's 
mouth  is  covered  with  a  piece  of  gauze,  the  operator  holds  the 
child's  nose,  slightly  compresses  the  epigastrium,  places  his  lips 
to  the  child's  and  blows  air  into  the  child's  mouth,  after  slight 
compression  of  the  chest  to  accomplish  expiration.  This  may 
l)e  repeated  once  or  twice,  a  fresh  piece  of  gauz^  being  used  or 
a  fresh  area  covering  the  mouth. 

Artificial  respiration  should  not  Ixj  used  oftener  than  thirty 
times  to  the  minute. 

In  Sylvester's  method  the  child  is  placed  upon  its  back,  a 
folded  towel  under  its  shoulders,  and  chin  raised.  The  op- 
erator, standing  at  the  head,  drawls  its  arms  over  its  head  for 
inspiration,  and  for  expiration  carries  them  down  over  the  chest, 
at  the  same  time  making  pressure  on  the  chest  wall. 


28  THE   DISEASES   OP    CHILDREN. 

In  Schultze's  method  the  child  is  supported  with  the  index 
fingers  in  the  axilla  with  its  back  to  the  operator.  Expiration 
is  produced  by  raising  the  child  and  allowing  the  feet  to  fall 
forward  over  the  face,  thus  compressing  the  diaphragm.  Inspi- 
ration is  produced  by  allowing  the  child  to  fall  forward  into  the 
first  position,  with  the  head  fully  extended,  thus  straightening 
the  trachea. 

Laborde  has  suggested  that  rhythmic  traction  on  the  tongue, 
acting  through  the  recurrent  laryngeal  nerve,  may  stimulate 
respiration. 

Dilatation  of  the  sphincter  ani  with  the  finger  is  a  stimulant  to 
respiration,  and  should  be  used  in  connection  with  the  other 
methods. 

The  pulmotor,  a  mechanical  device  for  artificially  inducing 
and  maintaining  respiration,  has  been  successfully  used  to  es- 
tablish respiration  in  asphyxia  of  the  new-born.  It  is  of 
greater  value  than  the  other  methods  of  artificial  respiration  as 
it  forces  oxygen  into  the  lungs. 

CARE  OF  THE  NEW-BORN. 

Authorities  differ  as  to  the  proper  time  to  ligate  the  cord. 
The  child  unquestionably  has  a  better  start  if  all  of  the  blood 
in  the  placenta  can  be  utilized  in  its  own  vessels  after  birth, 
hence,  ligation  of  the  cord,  when  the  pulsations  have  ceased,  at 
about  10  inches  from  the  child's  abdomen,  provided  respira- 
tion has  been  prompt,  gives  the  child  this  advantage.  The  cord 
is  ligated  2  inches  from  the  abdomen  and  a  second  ligature  is 
applied,  between  which  the  cord  is  cut.  The  ligature  material 
should  either  be  a  rubber  elastic  band,  tape  or  very  heavy  silk. 
By  using  a  rubber  band  which  can  be  applied  by  means  of  one 
of  several  applicators  on  the  market,  continuous  pressure  is  ex- 
erted on  the  vessels  as  the  Wharton's  jelly  atrophies,  and  hemor- 
rhage from  the  cord  prevented.  If  tape,  or  silk  is  used  the  cord 
should  be  frequently  inspected  during  the  first,  hour  or  two 
after  birth  to  guard  against  hemorrhage.  The  cord  may  be 
dressed  with  a  piece  of  sterile  gauze  3  inches  square,  cut  half 
across  its  middle.  The  cord  is  drawn  through  this  cut  and  over 
it  can  be  poured  a  dressing  composed  of  balsam  of  Peru  and 


THE   NEW-BORN. 


29 


castor  oil/  or  a  powder  composed  of 
one  part  salicylic  acid  and  three  parts 
of  boracic  acid.  Over  the  cord  is  then 
placed  an  uncut  piece  of  gauze  and  all 
is  confined  by  a  flannel  binder  6  inches 
wide,  applied  snugly  but  not  tightly. 
This  dressing  is  not  removed  except  it 
be  to  renew  the  oil  or  the  powder  until 
the  cord  drops  off,  which  usually  oc- 
curs between  the  fourth  and  seventh 
days.  I  have  seen  one  cord  remain  at- 
tached for  18  days.  If  at  the  end  of 
10  days  the  vessels  are  still  attached  a 
ligature  should  be  tied  close  to  the  um- 
bilicus and  the  stump  cut  away.  The 
umbilicus  should  be  left  perfectly 
smooth  and  dry  after  the  cord  drops 
off;  if  moist,  a  few  applications  of  2 
to  4  per  cent  solution  of  nitrate  of  sil- 
ver and  a  drying  powder  will  usually 
suffice.  The  flannel  binder  is  only 
worn  for  the  purposes  of  preventing 
an  accident  to  the  cord  before  it  sep- 
arates, and  a  knit  binder  is  substituted 
for  it  at  the  end  of  two  weeks. 

Too  frequently  a  new-born  child  is 
neglected  by  the  attending  physician. 
As  soon  as  the  cord  is  cut,  it  is  given 
to  the  nurse,  and  not  again  looked  at. 
Every  child  should  be  carefully  in- 
spected by  the  physician  before  it  is 
dressed.  Its  mouth  should  be  exam- 
ined for  presence  of  cleft  palate ;  ex- 
tremities for  deformities;  genitals  and 
anus  for  abnormalities ;  scrotum  for  the  ^'^ 
presence  of  the  testicles.  At  the  end 
of  six  or  eight  hours,  inquiry  should  be  made  to  learn  whether 


Funis    Band   Applicator 
(Kellogg). 


1  Balsam  of  Peru,   TTl  •  20  ;   fasfor  oil,  one  ounce. 


30  THE  DISEASES  OF   CHILDREN. 

the  bladder  and  rectum  have  been  evacuated.  If  the  passage  of 
urine  seems  painful,  this  may  be  due  to  a  constricted,  pinhole 
prepuce,  or  to  the  passage  of  uric  acid  sand  with  the  urine,  the 
latter  being  present  on  the  napkins  and  easily  seen.  If  no  me- 
conium has  been  passed  the  rectum  should  be  inspected  for  an 
imperforate  anus,  and  if  this  is  found  appropriate  measures 
taken  at  once  for  its  relief. 

The  skin  is  covered  with  a  cheesy-like  substance  called  vemix 
caseosa.  This  is  accumulated  to  a  considerable  extent  in  the 
flexures  and  folds  of  the  skin.  This  substance  can  be  easily 
removed,  if  disintegrated  by  the  application  of  some  oily  sub- 
stance. Vaseline,  olive  oil  or  unsalted  lard  is  rubbed  over  the 
child's  body  thoroughly,  the  face  being  wiped  off  with  a  greased 
piece  of  gauze.  A  shirt  and  napkin  are  applied  and  the  child 
wrapped  in  a  blanket  and  laid  upon  its  right  side  in  either  a 
crib  or  bassinet.  A  useful  bassinet  can  be  made  of  a  wicker 
clothes  basket  which  has  been  padded  and  a  pillow  placed  in  the 
bottom  upon  which  the  child  is  laid.  At  the  end  of  four  or  five 
hours  the  child  is  given  its  first  bath  while  lying  upon  the 
nurse's  lap,  water  at  the  temperature  of  100°  F.  is  used  and  the 
vernix  removed  with  a  soft  cloth  without  violence.  The  skin 
is  thoroughly  dried  and  pure  talcum  used  in  the  folds  and 
flexures  of  the  skin. 

Eyes. — Crede's  treatment  of  the  eyes  for  the  prevention  of 
ophthalmia  neonatorum  should  he  used  in  every  new-born  hahy's 
eyes.  No  patient  can  positively  be  said  to  be  free  from  gono- 
cocci,  and  if  the  treatment  is  reserved  for  those  cases  wliere 
there  is  a  history  of  a  purulent  vaginal  discharge  in  the  mother 
before  delivery,  many  severe  cases  will  be  encountered.  Tlie 
treatment  is  of  itself  entirely  harmless,  and  an  absolute  prophy- 
lactic. One  or  two  drops  of  a  2  per  cent  solution  of  nitrate  of 
silver  are  dropped  into  eacli  eye,  at  the  outer  eanthus.  Normal 
salt  solution  is  then  squeezed  into  each  eye  from  a  pledget  of 
gauze  or  medicine  dropper,  to  neutralize  any  excess  of  the  silver. 
If  any  irritation  results  from  this  treatment  it  is  very  slight  and 
transitory.  Other  salts  of  silver  have  been  suggested  as  a  sub- 
stitute for  the  nitrate,  as  argyrol,  ]>ut  none  are  as  effective  as 
the  one  first  suggested  by  Crede. 


THE   NEW-BORN.  31 

Mouth. — As  a  routine  the  mouth  should  be  washed  with 
boracic  acid  solution  before  and  after  each  nursing,  before  nurs- 
ing to  protect  the  mother's  nipple,  and  after,  to  remove  any 
particles  of  milk  remaining  in  the  folds  of  mucous  membrane. 
The  development  of  thrush  or  sprue  is  an  evidence  of  careless- 
ness and  neglect.  A  swab  of  soft  sterile  gauze  or  absorbent 
cotton  is  made  on  the  end  of  the  little  finger  and  wet  with 
boracic  acid  solution,  and  the  whole  of  the  inside  of  the  mouth 
carefully  and  gently  swabbed.  Violence  should  be  guarded 
against  as  an  abrasion  of  the  mucous  membrane  from  too  vig- 
orous rubbing  may  b€  the  site  of  an  infection. 

Bathing^. — The  child  should  be  given  a  daily  bath  upon  the 
lap  until  the  cord  drops  off,  the  baby  being  partly  covered  with 
the  bath  blanket.  Only  pure  castile  soap  should  be  used  in  the 
bath.  When  the  cord  has  dropped  off  and  the  navel  is  healed, 
the  baby  should  be  soaped  while  in  the  lap,  then  immersed  in  a 
baby's  bath  tub.  The  tub  can  be  made  collapsible,  of  rubber 
sheeting,  supported  on  legs  of  the  proper  length,  so  as  to  make 
it  the  correct  height  to  be  comfortable  and  convenient  for  the 
mother  or  nurse.  If  a  small  white  porcelain  tub  is  used  it  should 
be  placed  on  a  chair  or  stool.  A  folded  bath  towel  should  be 
laid  on  the  bottom  of  the  tub,  to  prevent  the  child  slipping. 

The  temperature  of  the  water  should  be  100°  F.  After  the 
baby  is  a  month  old  the  water  should  be  cooled  to  90°  F.  before 
the  child  is  removed.  When  removed  from  the  water  it  is 
wrapi^ed  in  the  bath  blanket,  carefully  dried,  the  buttocks  and 
flexures  powdered,  and  dressed  immediately.  The  bath  should 
always  be  given  before  nursing,  never  just  after  being  fed.  It 
may  be  found  most  convenient  and  comfortable  to  the  child  to 
give  tlie  bath  just  before  the  last  feeding  at  bed  time.  In  hot 
weather  a  second,  bath  may  be  given  at  bed  time. 

A  folded  napkin  can  be  placed  under  the  child  to  soak  up 
any  urine  which  penetrates  the  first  one.  Ruhher  napkim 
should  never  be  used. 

Buttocks. — The  first  discharge  from  the  bowels  is  meconium. 
It  is  composed  of  epithelial  cells  and  biliary  salts,  is  black  and 
of  the  consistence  of  tar.  It  is  difficult  to  remove  from  the 
skin,  and  when  it  remains  in  contact  with  it  for  some  time  irri- 


32  THE   DISEASES   OF    CHILDREN. 

tation  and  maceration  take  place,  and  an  intertrigo  follows.  An 
intertrigo  is  always  the  sign  of  carelessness.  As  soon  as  soiled 
the  napkin  should  be  removed  and  the  skin  very  gently  washed 
with  a  soft  cloth  and  water,  without  soap,  and  carefully  dried 
and  powdered. 

Genitals. — The  female  genitals  need  but  little  care  except  ordi- 
nary cleanliness  and  prompt  removal  of  soiled  napkins  both 
day  and  night.  The  possibility  of  the  development  of  a  vulvo- 
vaginitis, either  simple  or  specific,  should  be  borne  in  mind.  The 
treatment  of  the  latter  is  referred  to  in  another  place. 

Indiscriminate  and  universal  circumcision  of  a  male  infant 
should  not  be  advocated.  If,  when  the  baby  is  a  month  old,  the 
prepuce  is  reflected,  adhesions  broken  up  and  the  smegma  re- 
moved, and  vaseline  placed  well  around  the  corona  glandis,  the 
necessity  for  circumcision  is  averted.  This  will  prevent  the 
pinhole  opening  and  long  prepuce  so  frequently  seen  in  boy 
babies  in  whom  this  precaution  has  been  omitted.  This  reflec- 
tion should  be  repeated  once  every  second  day  for  a  week,  then 
once  a  week,  for  the  sake  of  cleanliness.  I  liave  seen  one  case 
in  which  an  infection  occurred  after  the  first  reflection  at  the 
site  of  one  of  the  abrasions  where  a  rather  tight  adhesion  had 
occurred,  and  considerable  pus  accumulated  behind  the  corona, 
this  being  possible  as  the  mother  had  failed  to  again  completely 
reflect  the  prepuce  to  cleanse  it.  The  mother  should  be  cau- 
tioned in  regard  to  the  possibility  of  a  paraphimosis  developing 
from  allowing  a  prepuce  to  remain  reflected  behind  the  corona 
too  long  at  a  time. 

No  jnfant  should  ever  be  allowed  to  sleep  in  the  same  bed 
with  its  mother. 

PREPARATION  FOR  THE  BABY. 

The  baby's  basket  should  be  prepared  some  weeks  before 
birth,  and  the  following  articles  for  it  are  suggested : 

Pincushion  containing  three  sizes  of  safety  pins. 
Soft  hair  brusli. 

Soap  box  witli  white  castile  soap. 

Talcum   powder    in    box   with    perforated    top.      {Ponder    Puff    is    tin- 
hygienic. ) 


(THE  NEW-BOR^r.  33 

White  vaseline  in  tube. 

Benzoinated  oxide  of  zinc  ointment. 

Bath  thermometer. 

Hot-water  bag,   two-quart,   with  removable  flanellette  bag  with  draw 

string. 
Saturated  solution  of  boracic  acid. 
One  pair  blunt  scissors. 
Absorbent  cotton,  wrapped  in  small  towel. 
Soft  towels  made  of  old  damask. 
Apron  bath  blanket  of  outing  flannel  made  of  two  thicknesses  sewed 

together  at  the  top  only. 
Wooden  tooth  picks  to  be  wrapped  with  absorbent  cotton  at  one  end  to 

be  used  as  swab  for  cleaning  nose. 
Two  or  three  thin  flannel  bands,  six  inches  wide. 
Soft  linen  of  double  thickness,  or  cheese  cloth  for  wash  cloths. 
Squares  of  sterile  gauze  for  washing  mouth. 
Medicine  dropper. 

A  box  or  special  drawer  should  be  provided  for  the  baby's 
clothes.     The  outfit  should  consist  of  the  following: 

Four  dozen  napkins  made  of  cotton  birdseye,  two  sizes,  20  inches  and 

24  inches  wide.     Either  square  or  double. 
Six  flannel  skirts. 
Four  silk  and  wool  shirts. 
Four  knit  bands. 
Four  outing  flannel  gowns. 
Nine  white  slips,  nainsook  or  longcloth. 
Three  white  cambric  petticoats.      (To  be  worn  only  in  summer,  and  not 

with  flannel  ones.) 
Two  white  baby  blankets  or  comforts. 
Two  knitted  sacks. 

Two  or  three  qaiilted  pads  for  baby's  bed,  one  yard  square. 
One  cloak — ^two  caps — one  veil. 
Two  pieces  rubber  cloth,  one  yard  square. 
Fine  hair  pillow,  10  x  12  in.  for  buggy. 
Six  pillow  slips. 
Six  sheets  for  bassinet. 
Skirt  stretcher. 
Stocking    stretcher.     For    drying    these    garments    without    shrinking 

them. 
One  flannel  bag  for  tying  about  child's  waist  when  out  of  doors. 

Much  help  can  be  had  in  making  the  baby's  clothes  by  using 
Butterick  's  fashions,  set  No.  7080. 


34  THE   DISEASES   OP    CHILDREN, 

CARE  OF  NAPKINS. 

Too  great  emphasis  cannot  be  laid  on  the  importance  of 
careful  washing  of  the  napkins,  both  when  soiled  with  a  move- 
ment from  the  bowels  and  when  wet  with  urine  only.  They 
should  be  washed  with  soap  and  soda,  followed  by  several  rins- 
ings in  cold  water,  and  dried  out  of  the  nurserj%  folded  smooth 
by  hand  and  not  ironed,  as  ironing  renders  them  less  absorbent. 
I  have  seen  several  cases  of  severe  eczema,  limited  to  the  part 
of  the  body  covered  by  the  napkin,  where  inquiry  developed  the 
fact  that  the  napkin  was  being  used  after  being  wet  three  or  four 
successive  times  and  simply  dried  without  washing. 

As  soon  as  a  napkin  is  soiled  it  should  be  taken  to  the  bath 
room  or  closet  and  the  movement  scraped  off  with  a  knife  kept 
for  that  purpose,  wiping  the  scrapings  on  a  piece  of  toilet  paper 
and  throwing  it  in  the  closet.  The  diaper  is  then  put  in  a 
covered  porcelain  bucket,  which  should  be  provided,  containing 
a  weak  formaldehyde  solution  or  a  1  to  100  carbolic  acid  solu- 
tion in  which  the  soiled  napkins  can  be  placed  until  washed. 

THE  NURSERY. 

The  nursery  should  be  a  bright  cheery  room,  with  an  open 
fireplace  for  winter  heating,  if  possible.  The  temperature 
should  not  be  over  70°  F.,  and  the  air  should  be  changed  at  least 
once  daily,  first  removing  the  child  and  opening  all  windows  for 
a  half  to  one  hour.  It  should  have  not  less  than  1000  cubic 
feet  of  air  space,  and  more  if  possible.  Emphasis  should  be 
laid  upon  the  importance  of  a  moist  air  in  steam-heated  or  hot- 
air-heated  houses. 

The  walls  should  by  preference  be  painted  and  the  floor  un- 
carpeted,  either  hardwood  or  painted.  This  makes  it  possible 
for  the  floor  to  be  wiped  up  and  not  swept,  thus  avoiding  dust. 
The  use  of  a  compressed  air-cleaning  device  in  private  houses 
should  be  recommended,  where  there  are  children,  especially. 
There  should  be  plenty  of  light,  when  the  child  is  awake,  with 
dark  shades  to  darken  the  room  when  asleep,  and  the  room  should 
be  at  least  5°  cooler  at  this  time.  In  favorable  weather  the  child 
can  sleep  in  its  buggy  out  of  doors,  protected  from  the  wind  and 
its  eyes  from  the  light. 


THE   NEW-BORN.  35 

The  skin  of  the  new-born  is  very  delicate,  and  is  covered  wdth 
lanugo,  a  fine  downy  hair,  which  is  soon  rubbed  off.  There  is 
frequently  desquamation  of  the  skin,  either  general  or  on  vari- 
ous parts  of  the  body. 

Most  infants  have  a  rather  heavy  suit  of  Jmir,  at  birth,  and 
during  the  first  three  months  this  is  usually  rubbed  off,  first 
on  the  back  of  the  head,  w^iere  it  comes  in  contact  with  the  bed, 
and  this  is  replaced  by  a  finer  and  softer  growth. 

In  the  new-born  the  temperatitre  is  usually  elevated  1°  or  2°  F. 
A  large  number  of  observations  made  by  Edwards,  Keating  and 
Holt,  have  demonstrated  that  the  temperature  in  infants,  be- 
tween ages  of  one  and  twelve  months,  ranges  between  99°  F, 
and  99.5°  F.,  and  that  only  a  temperature  of  100°  F.  or  over 
should  be  considered  as  abnormal.  A  continuous  subnormal  tem- 
perature is  one  of  the  best  indications  of  poor  nourishment. 

If  no  deformity  exists,  an  infant  should  pass  imne  during 
the  first  two  or  three  hours  after  birth.  The  first  secretion  is 
usually  clear,  but  it  may  become  turbid,  or  contain  a  deposit 
sufficiently  thick  to  stain  the  napkin,  or  distinct  particles  of 
uric  acid  sand  may  be  passed.  Some  pain  is  usually  experi- 
enced when  the  latter  is  passing.  The  urine  later  in  infancy 
is  very  light  in  color  and  of  low  specific  gravity. 


CHAPTER  III. 
DISEASES  AND  INJURIES  OF  THE  NEW-BORN. 

Caput  Succedaueum. — This  is  a  eollection  of  blood  serum  in 
the  cellular  tissue  of  the  presenting  part  of  the  child.  It  is  due 
to  a  constriction  of  the  veins  of  the  skin  by  the  bony  pelvis 
preventing  a  free  return  of  the  blood  and  allowing  an  escape 
of  the  serum  into  the  cellular  tissue.  It  is  present  at  birth,  and 
in  vertex  presentations,  the  scalp  may  be  thick  enough  to 
make  it  impossible  to  detect  any  of  the  sutures  or  fontanelles. 
The  extravasation  has  usually  been  absorbed  by  the  end  of  the 
second  day,  and  the  scalp  and  head  have  a  normal  appearance. 

Cephalhematoma. — This  is  an  extravasion  of  blood  from  a 
ruptured  capillary  between  the  periosteum  and  the  bone.  It 
usually  does  not  occur  until  the  third  or  fourth  day,  and  is  most 
frequently  found  over  one  or  both  parietal  bones.  The  extrava- 
sation of  blood  is  limited  entirely  to-  the  bone  over  which 
it  occurs,  as  the  periosteum  is  bound  down  to  the  edges  of  the 
bone.  If  over  both  parietals,  there  is  a  deep  sulcus  between, 
corresponding  to  the  sagittal  suture,  and  looking  at  the  head 
from  behind  it  has  the  appearance  of  two  half  oranges  under 
the  skin  on  opposite  sides. 

Cephalhematoma  must  be  differentiated  from  hernia  cerehri. 
In  the  latter  the  tumor  is  a  pulsating  one  and  in  cephalhematoma 
it  is  not.  Crying  will  increase  the  tension  of  a  hernia  but 
causes  no  change  in  the  cephalhematoma.  Cephalhematoma  is 
not  always  due  to  injuries  sustained  in  prolonged,  natural  or 
instrumental  deliveries,  in  vertex  presentations.  As  an  instance 
may  be  mentioned  two  cases  under  my  observation,  both  in 
breech  presentation.  One  was  a  double  cephalhematoma,  the 
other  triple,  hemorrhage  occurring  over  both  parietal  and  the 
occipital  bones. 

In  rare  instances  suppuration  ensues,  in  which  event  all  the 

36 


DISEASES   AND   INJURIES  OF    THE   NEW-BORN.  37 

signs  of  an  abscess  will  be  present,  and  surgical  intervention 
is  called  for  at  once. 

Treatment. — The  temptation  is  to  interfere  in  cases  of 
cephalhematoma,  but  under  no  circumstances  should  they  be 
interfered  with.  If  protected  from  injury  from  pressure,  na- 
ture takes  care  of  the  effused  blood  by  absorption,  and  in  the 
majority  of  eases  after  being  absorbed,  no  trace  of  them  can  be 
found,  unless  it  be  a  small  ridge  at  the  extreme  edges  of  the 
tumor.  Incision  may  be  practiced  under  the  strictest  aseptic 
precautions,  but  the  difficulty  of  maintaining  pressure  upon  the 
head  to  prevent  the  further  effusion  of  blood  after  evacuation 
of  the  clot  must  be  borne  in  mind. 

Umbilical  Hemorrhage. — Hemorrhage  from  the  cord  may 
occur  before  it  drops  off,  either  from  a  loosely  applied  ligature 
or  from  the  vessels  being  cut  through  by  a  small  ligature  being 
tied  too  tightly.  Both  of  these  accidents  can  be  prevented  by 
the  use  of  a  rubber  elastic  ligature,  in  the  form  of  a  small 
rubber  ring  of  caliber  smaller  than  the  circumference  of  the 
cord,  which  is  stretched  and  slipped  over  the  severed  end  of  the 
cord,  by  one  of  the  appliances  for  that  purpose.  A  ligature  of 
this  kind  exerts  continuous  pressure  on  the  vessels  as  the  Whar- 
ton's jelly  dries,  and  bleeding  is  more  effectually  prevented 
than  can  possibly  be  done  by  any  other  means. 

Hemorrhage  may  occur  from  the  umbilicus  after  the  cord  has 
dropped  off,  during  the  second  or  third  week,  and  in  all  such 
cases  there  is  a  tendency  to  hemorrhage  as  is  found  in  hemo- 
philia or  the  "bleeders." 

Pressure  upon  the  bleeding  vessels  at  this  point  is  very  diffi- 
cult to  accomplish.  If  there  is  but  a  small  amount  of  oozing, 
the  application  of  persulphate  of  iron  or  a  one  to  one  thousand 
solution  of  adrenalin  may  control  it.  Needles  carried  under  the 
umbilicus  at  right  angles,  and  wrapped  with  a  figure  of  eight 
suture  should  be  tried  in  the  severer  cases. 

Granulating  Umbilicus. — 'After  the  separation  of  the  cord, 
one  or  more  of  the  vessels  may  be  left  as  a  small  granular  spot, 
from  which  there  is  a  serous,  or  seropurulent  discharge,  an 
eczema  of  the  skin  of  the  umbilicus  sometimes  following. 

Treatment. — A  cure  may  be  had  by  the  application  of  a  solu- 


38 


THE   DISEASES   OF    CHILDREN. 


tion  of  nitrate  of  silver,  30  to  40  grains  to  the  ounce,  followed 
by  a  dry,  absorbent  dressing,  as  powdered  boracie  acid  and 
starch,  equal  parts,  this  being  repeated  once  daily. 

In  the  event  that  there  is  a  protrusion  of  the  stump  of  the  ves- 
sels, after  the  cord  drops  off,  a  silk  ligature  should  be  thrown 


Fig.    6. — Umbilical   granulation   removed   by    ligature   six   weeks    after   birth. 

around  its  base  and  tied  tightly.     AYhen  this  stump  separates 
it  will  promptly  heal  under  a  dry  dressing. 

Hemorrhage. — New-born  babies  are  specially  prone  to  de- 
velop hemorrhages,  and  because  of  the  indefinite  knowledge  to- 
day of  the  true  pathology  of  the  condition,  the  symptom  complex 
is  now  called  in  general  terms,  "hemorrhage  of  the  new-born." 
Formerly  an  attempt  was  made  to  describe  each  case  according 
to  the  location  of  the  hemorrhage,  in  this  way  having  a  number 


DISEASES   AND   INJURIES   OF   THE   NEW-BORN.  39 

of  terms,  descriptive  of  the  same  general  underlying  disease. 
Kling,  Genrich  and  Runge,  quoted  by  Koplik,  state  that  hem- 
orrhagic disease  in  the  new-born  occurs  about  once  in  1000  cases. 

Etiology. — The  etiology  of  the  condition  is  obscure;  but  in 
view  of  the  fact  that  fever  is  a  prominent  symptom  in  most 
cases,  the  consensus  of  opinion  is  that  the  most  frequent  causa- 
tive factor  is  a  general  septic  infection.  The  new-bom  develop 
sepsis  easily  and  the  entrance  to  the  system  of  the  offending 
organisms  may  be  at  many  points,  the  gastrointestinal  tract, 
the  mouth,  the  genitourinary  tract  and  the  umbilicus  being  the 
most  frequent  portals.  Gartner  claims  to  have  found  bacilli 
in  the  feces  in  cases  of  melena,  proving  his  theory  that  this 
form  of  hemorrhages  is  a  coceal  sepsis.  In  Winckel  's  disease, 
a  condition  closely  similar,  a  bacteremia  is  present,  streptococci 
and  bacilli  having  been  found  in  various  organs  and  the  blood. 
The  changes  whch  occur  in  syphilis,  which  has  been  named  as  a 
cause,  are  in  the  blood  vessels  rather  than  in  the  blood  itself. 

Among  the  other  causative  factors  have  been  mentioned  pre- 
maturity, atelectasis,  deformity  of  the  heart,  persistent  foramen 
ovale  or  ductus  arteriosus,  ulcer  of  the  stomach  and  intestine, 
the  latter  due  to  a  venous  stasis,  followed  by  a  thrombosis ;  fatty 
degeneration  of  the  arterioles ;  extreme  delicacy  of  the  blood 
vessels ;  congenital  obstruction  of  the  portal  venous  system ;  con- 
gestion from  pulmonary,  cardiac  or  hepatic  disease;  excessive 
secretion  of  gastric  juice  resulting  in  partial  digestion  of  the 
mucosa  of  stomach  and  intestine,  congenital  hemophilia  and  the 
great  changes  taking  place  in  the  circulation  incident  to  birth. 

Hemorrhages  in  the  new-bom  may  take  place  from  any  organ 
and  the  hemorrhage  may  occur  before  birth  or  subsequently. 
When  postnatal,  it  usually  occurs  within  the  first  three  days 
after  birth. 

In  Dr.  Townsend's  50  cases,  quoted  by  Rotch,  he  gives  the  fol- 
lowing location  of  the  hemorrhages : 

Intestines    20       Ecchymoses  in  Skin 21 

Stomach    14       Scratch  of  Skin 1 

Nose 12       Cephalhematoma  3 

Mouth    14       Meninges  4 

Umbilicus 16       Abdominal   Cavity .   2 


40  THE   DISEASES   OF    CHILDREN. 

Pleural   Cavity    2  chyniosis  of  skin 3 

Lung    1       Gastroenteric  tract  alone    19 

Thymus  Gland    1       From  umbilicus  alone 3 

From    Gastro-enteric    tract,    nose,  Ecchymoses  of  skin  alone 6 

umbilicus    accompanied    by    ec- 

Holt  gives  Hitter's  statistics  in  190  cases  as  follows:  Hemor- 
rhage from  the  umbilicus,  138  (umbilicus  alone,  97)  ;  intestines, 
39 ;  mouth,  28 ;  stomach,  20 ;  conjunctivae,  20 ;  ears,  9. 

I  have  seen  one  case  of  hemorrhage  into  the  suprarenal  gland, 
a  number  of  cases  of  cephalhematoma,  both  single  and  double, 
and  the  case  shortly  to  be  reported,  of  melena,  or  hemorrhage 
from  the  stomach  and  intestine.  In  the  case  of  hemorrhage  in 
the  suprarenal  capsule,  reported  in  full  in  the  Archives  of 
Pediatrics,  November,  1892,  the  right  suprarenal  gland  was 
distended  with  blood  to  the  size  of  an  orange,  and  blood  clots 
were  found  behind  the  kidney  and  in  the  free  peritoneal  cavity. 
The  diagnosis  was  not  made  in  this  case  during  life,  the  most 
prominent  symptom  being  a  profound  jaundice.  The  hemor- 
rhage was  found  postmortem. 

Hemorrhage  from  the  gastrointestinal  tract  may  occur  inde- 
pendently of  bleeding  from  any  other  organ  and  is  called 
melenge.  If  from  the  mouth  alone,  the  quantity  of  blood  lost  is 
usually  small,  if  from  the  stomach  large  quantities  may  be  vom- 
ited or  passed  from  the  bowel  in  form  of  clots.  As  stated,  it 
has  been  thought  by  different  observers  to  be  due  to  an  ulceration 
of  the  mucous  membrane,  following  septic  emboli  of  its  vessels,  a 
digestion  of  the  membrane  by  a  hyperacid  gastric  juice,  or  to 
a  general  pyogenic  septic  condition.  Like  the  other  forms  it 
usually  occurs  during  the  first  three  days,  and  with  great  variety 
as  late  as  the  ninth  day.  The  child  may  first  vomit  some  red 
blood,  followed  soon  afterward  by  a  coffee-ground  vomit,  or 
blood  may  first  be  noticed  in  the  discharges  from  the  bowel.  The 
meconium,  being  very  dark  in  color,  may  cause  blood  in  the 
actions  to  be  overlooked,  unless  it  is  passed  in  large  clots.  If 
passed  in  considerable  quantity  the  napkin  at  the  edge  of  the 
mass  will  be  stained  a  reddish  color,  or  if  blood  is  suspected 
a  microscopic  examination  will  reveal  the  blood  corpuscles.  It 
should  be  borne  in  mind,  before  a  diagnosis  of  hemorrhagic  dis- 


DISEASES   AND   INJURIES   OP   THE   NEW-BORN.  41 

ease  is  made,  that  the  source  of  blood  may  have  been  a  fissured 
nipple,  or  blood  from  the  nose  which  has  been  swallowed.  I 
have  seen  one  case  which  caused  considerable  uneasiness  until 
it  was  finally  decided  that  the  source  of  the  blood  was  from  a 
cracked  nipple. 

Prognosis. — The  prognosis  in  hemorrhagic  diseases  of  the  new- 
born varies  according  to  the  site  of  the  bleeding.  Taken  as  a 
whole  the  mortality  is  given  by  various  authors  differently: 
Townsend's  eases  62  per  cent,  and  in  another  series  of  709,  79 
per  cent ;  Williams  places  it  at  60  per  cent ;  Holt  states  that 
no  observer  has  seen  more  than  one-third  of  his  cases  recover. 

The  following  history  is  given  as  illustrative  of  that  form  of 
hemorrhage  known  as  melena: 

Child  of  III  Gravida.  First  labor  instrumental,  occiput  posterior,  forceps 
rotation.  Second  labor  normal,  but  prolonged.  Third  labor  began  at  12 
midnight,  birth  at  1  p.  m.  following  day.  Vertex  presentation;  first  posi- 
tion; mechanism  and  labor  normal.  Child,  female;  weight,  9  pounds  8 
ounces;  normal  in  every  way;  primary  respiration  prompt  and  normal; 
no  cyanosis;  nursed  vigorously  when  put  to  the  breast.  An  abundant  sup- 
ply of  milk  appearing  on  the  third  day.  On  the  third  day  at  noon  the 
child  vomited  red  blood,  sufficient  in  quantity  to  stain  its  clothes  through 
and  through.  Shortly  after  this  a  very  large  amount  of  meconium  was 
passed  containing  red  blood,  very  easily  distinguished  in  the  black  meconium 
mass.  Child  pale  and  blue  around  the  nose,  pulse  weak  and  rapid;  re- 
fused to  nurse  after  vomiting  blood,  the  nursing  being  discontinued  after 
hemorrhage  was  reported. 

For  five  days  vomiting  of  blood  and  hemorrhage  from  the  bowels  oc- 
curred, the  latter  quite  profuse  and  being  passed  in  masses  of  clots. 

After  treatment  with  subcutaneous  injection  of  gelatin  solution,  2  per 
cent,  described  below,  the  cliild  made  a  good  recovery;  at  the  end  of  the 
second  week  it  had  regained  its  birth  weight  and  continued  to  thrive. 

Treatment. — Various  methods  of  treatment  have  been  sug- 
gested by  different  authors.  Koplik  suggests  the  cold  coil;  er- 
gotin,  one-half  to  three-fourths  grain  subcutaneously :  Henoch 
suggests  one  drop  of  liquor  ferri  sesquichloridi  in  barley  water 
every  hour;  Williams  suggests  gallic  acid,  gr.  i,  every  three 
hours;  oil  of  turpentine,  m.  i,  in  mucilage  every  hour;  extract 
of  krameria  gr.  ii,  every  two  or  three  hours,  or  an  injection  into 
the  bowel  of  an  infusion  4  to  5  ounces,  and  calcium  chloride 
to  increase  the  coagulability  of  the  blood. 


42  THE  DISEASES  OF    CHILDREN. 

The  subcutaneous  injection  of  gelatin  employed  in  the  case 
reported  was  followed  by  very  prompt  recovery. 

The  English  gelatin  is  used,  as  the  ordinary  commercial  gelatin 
has  been  found  contaminated  with  the  tetanus  bacillus.  Two 
sterilizations  are  made  in  order  to  be  sure  this  organism  is 
destroyed.  An  ordinary  antitoxin  syringe  or  aspirator,  without 
too  large  a  needle  can  be  used  for  the  injection.  The  cellular 
tissue  of  the  back  can  be  used,  the  solution  warmed,  and  20  cc. 
can  be  slowly  injected. 

P.  Emile  Weil  ^  while  studying  hemophilia  began  the  use  of 
fresh  animal  sera  injected  either  intravenously  or  subcutaneously 
as  a  means  of  controlling  or  preventing  hemorrhage.  These  ob- 
servations brought  out  the  fact  that  the  serum  from  horses,  rab- 
bits, men  and  cattle  had  the  power  of  controlling  hemorrhage 
by  increasing  the  coagulability  of  the  blood ;  that  the  serum  from 
beef  possessed  too  much  toxicity;  that  the  serum  should  be  less 
than  two  weeks  old ;  that  the  dose  was  15  to  30  cc. ;  it  is  of 
service  locally  in  causing  clotting ;  that  the  increased  coagulability 
persisted  for  a  period  of  from  15  days  to  several  weeks;  that 
sporadic  hemophilia  and  acute  purpura  gave  the  most  definite 
cures. 

As  long  as  there  is  any  bleeding  from  the  stomach  food  can- 
not be  given  in  this  way,  but  it  can  be  given  by  nutrient  enemata. 

A  case  has  been  very  recently  under  my  observation  in  which 
the  hemorrhage  was  from  the  bowel  alone.  On  the  fourth  day  a 
very  large  bloody  movement  was  passed,  followed  in  twenty-four 
hours  by  six  smaller  ones.  The  child  showed  decided  depression, 
pallor,  listlessness  and  crying  at  intervals,  sweating  and  nursed 
poorly.  It  had  been  given  two  minims  of  1 :1000  adrenalin  solu- 
tion without  effect,  and  on  the  second  morning  shortly  after  a 
stool  containing  bright  red  blood,  it  was  given  714  cc.  of  normal 
blood  serum  in  the  thigh  hypodermatically,  after  which  no 
further  bleeding  occurred. 

UMBILICAL  HERNIA. 

Etiology. — The  failure  of  the  umbilical  ring  to  firmly  unite 
after  the  cord  drops  off  is  the  chief  cause.  Contributory  cause 
is  the  continuous  crying  of  babies  subject  to  colic,  hunger,  etc.,  or 

iLeary:    Boston  Medical  and  Surgical  Journal.,  vol.  dix,  No.  3. 


DISEASES   AND   INJURIES   OF   THE   NEW-BORN. 


43 


who  strain  from  constipation.  The  tumor  varies  in  size  from  a 
small  knuckle  to  a  large  protuberance. 

Contents. — The  contents  of  the  sac  may  be  omentum  alone  or 
gut,  with  or  without  omentum. 

Treatment. — This  is  either  surgical  or  palliative.  Cures  can  be 
obtained  by  the  use  of  an  adhesive  strip  2  inches  wide,  and  long 


Fig.     7. — Adhesive    strap    for    umbilical    hernia. 

enough  to  reach  to  the  anterior  axillary  line  on  each  side.  The 
hernia  is  reduced,  a  pad  is  made  of  a  button  mold,  covered  with 
adhesive  plaster,  or  of  several  thicknesses  of  plaster,  and  placed 
over  the  ring.  One  end  of  the  plaster  is  applied  and  drawn  over 
the  umbilicus,  the  pad  in  place,  and  the  skin  over  the  umbilicus 
drawn  up  into  small  folds.  When  the  adhesive  is  changed,  which 
should  be  done  every  week  or  ten  days,  or  as  often  as  loosened, 
the  finger  is  placed  beneath  the  pad  and  held  until  the  new  strip 
is  applied. 


44  THE  DISEASES  OF   CHILDREN. 

Should  the  hernia  become  irreducible,  resort  should  be  had  to 
surgery  at  once. 

ATELECTASIS. 

Definition. — This  is  a  condition  of  the  lungs  in  which  all  of 
a  lobe  or  a  portion  of  one  remains  collapsed  after  birth,  the  lung 
remaining  as  in  the  fetal  state. 

Etiology. — The  condition  usually  follows  an  attack  of  as- 
phyxia neonatorum.  If  the  primary  wiping  out  of  the  mouth 
and  nose  is  not  done,  mucus  may  be  aspirated  and  mechanically 
plug  up  one  of  the  bronchial  tubes,  permanently  closing  it,  al- 
lowing all  lung  tissue  supplied  by  it  to  remain  collapsed.  Pre- 
maturity is  a  contributing  cause. 

Pathology. — The  surface  of  the  lung  subject  of  atelectasis 
shows  depressions,  corresponding  to  the  undilated  portion,  with 
air  in  surrounding  tissue.  These  areas  do  not  crepitate  on  pres- 
sure and  if  part  of  the  affected  portion  is  excised  it  will  sink 
in  water.  Much-dilated  bronchioles,  areas  of  compensatory 
emphysema,  surround  the  collapsed  portion. 

Symptoms. — Practically  the  only  diagnostic  sign  of  impor- 
tance is  the  presence  of  cyanosis  with  no  heart  lesion  being 
found.  The  child  does  not  thrive,  is  bluish  in  color,  especially 
when  crying,  and  the  cry  is  feeble.  Convulsions  may  rarely 
be  seen.  The  physical  signs  are  of  little  assistance  in  reaching 
a  diagnosis.  Owing  to  the  emphysematous  areas  around  the 
atelectasis,  no  dulness  or  bronchial  breathing  can  be  ol)tained. 
The  respiratory  murmur  is  feeble  and  slightly  harsher  than 
normal. 

Treatment. — The  principal  treatment  is  that  of  prevention,  by 
attempting  to  cause  the  child  to  take  deep  inspirations  imme- 
diately after  birth.  The  methods  of  artificial  respiration  men- 
tioned elsewhere  should  be  employed  early. 

ICTERUS. 

Jaundice  is  present  in  from  one-third  to  one-half  of  all  new- 
born infants.  The  depth  of  the  discoloration  may  be  a  very 
slight  yellow  tinge  of  the  skin  and  con.iunctiva,  usually  classi- 
fied as  the  (a)  Mild  Form,  and  a  deep  injection  of  these  tissues 
the  (b)  Grave  Form. 


DISEASES   AND   INJURIES  OF   THE  NEW-BORN,  45 

Etiology. — Many  causes  have  been  suggested.  Sepsis  causing 
a  fatty  degeneration  of  the  liver  has  been  named  as  one  of  the 
principal  causes.  Changes  in  the  circulation  accident  to  birth 
has  also  been  named.  The  cause  may  be  mechanical,  as  a  tumor, 
as  in  the  case  of  suprarenal  hemorrhage  (page  40),  pressing  on 
the  gall  bladder  and  ducts.  The  condition  may  be  hematogenous 
in  character. 

Symptoms. — In  the  mild  form  there  may  be  a  slight  discolora- 
tion of  the  conjunctiva  and  of  the  skin  of  the  face,  chest  and 
back,  or  there  may  be  a  deep  injection  of  the  skin  of  the  entire 
body,  discoloration  of  the  urine  and  light  colored  movements. 
These  changes  usually  appear  by  the  end  of  the  first  week  and 
persist  for  a  week  or  ten  days,  with  a  gradual  return  to  normal 
conditions.  The  child  may  be  slightly  apathetic,  nurse  poorly 
and  sleep  more  than  usual  during  this  time,  with  a  gradual  re- 
turn to  normal  in  one  or  two  weeks. 

In  the  grave  form  there  may  be  a  congenital  malformation 
of  bile  ducts  or  gall-bladder,  with  cirrhotic  changes  in  the  liver. 
The  symptoms  are  the  same  as  in  the  mild  form  save  they  are 
all  intensified ;  umbilical  and  other  hemorrhages  are  more  often 
seen,  and  death  ensues  promptly. 

Treatment. — Saline  enemata  once  or  twice  daily  is  of  great 
benefit.  The  ordinary  cases  usually  require  no  treatment  except  a 
dose  of  calomel  or  castor  oil. 

SEPSIS. 

Etiology. — This  condition  is  due  to  an  infection  of  the  new- 
born by  one  or  more  of  the  pus-producing  organisms,  the  strep- 
tococcus or  the  staphylococcus  being  the  most  frequent  form. 
The  most  favorable  site  for  entrance  of  the  organism  is  the  um- 
bilicus, either  before  or  after  the  separation  of  the  stump.  The 
infecting  organism  may  be  carried  to  this  point  by  the  capilla'ry 
action  of  an  infected  napkin  ;  hence  the  necessity  for  an  antiseptic 
dressing  to  the  umbilicus  until  the  navel  has  healed. 

The  following  portals  of  entry  of  the  organism  may  be  men- 
tioned: Injuries  and  abrasions,  as  in  a  forceps  operation,  with 
an  infection  after  birth ;  abrasion  of  the  mucoiis  membrane  of 
the  mouth;  septicemia  of  the  mother  during  the  later  weeks 


46  THE  DISEASES  OP   CHILDREN. 

of  pregnancy;  putrefaction  of  the  liquor  amnii,  with  ingestion  or 
aspiration  of  this  by  the  child  before  and  during  labor;  or  a 
violent  vaginitis  and  encLocervioitis  of  the  mother  before  birth 
and  infection  of  child  in  its  progress  through  the  canal;  sup- 
puration of  the  mammary  gland  during  lactation,  and  an  infec- 
tion of  a  milk  duct,  with  a  contamination  of  the  milk,  the  infec- 
tion being  through  the  gastrointestinal  tract;  or  an  infected 
wound  followng  clipping  of  the  frenum  linguoR  in  tongue  tie 
or  following  circumcision. 

Systemic  Symptoms. — The  first  evidence  of  the  condition 
usually  appears  during  the  first  week  and  may  be  a  failure  of 
the  child  to  nurse.  If  the  infection  has  been  at  the  navel  and 
there  is  peritoneal  involvement,  or  an  inflammation  of  the  ves- 
sels under  the  anterior  abdominal  wall,  there  is  continuous 
crying,  distension  of  the  abdomen  and  the  child  lies  with  legs 
drawn  up.  The  temperature  is  high  but  fluctuating;  jaundice 
is  present  when  the  liver  is  involved;  pulse  rapid  and  small; 
skin  hot  and  dry,  and  there  may  be  petechial  spots  develop  or 
large  ecchymotic  areas,  frequently  they  appear  on  the  part  which 
is  in  contact  with  pillow  and  bed. 

Prognosis  is  very  grave. 

Treatment. — Support  and  nourishment  offer  the  only  possible 
hope  of  relief.  If  the  child  is  unable  to  nurse,  rectal  feeding 
and  gavage  must  be  resorted  to,  using  by  the  former  completely 
peptonized  milk,  and  by  gavage,  breast  milk,  if  it  can  be 
obtained. 

CASE  I.  Baby  D,  born  of  primiparous  mother,  after  a  tedious  labor, 
terminated  by  instrumental  delivery,  which  was  easy.  No  abrasions  or 
abnormality  noticed.  Mother  developed  sepsis  during  the  first  week,  with 
temperature  to  106°  F.,  on  one  occasion.  Local  focus  of  infection  found 
in  posterior  vaginal  culdesac  which  had  sustained  a  rent  in  the  mucous 
membrane  during  the  delivery.  Cephalhematoma  over  left  parietal  devel- 
oped on  third  day;  fever  began  evening  of  third  day,  continuous  and  high, 
often  to  104°  F. ;  hemorrliage  from  frenum,  wliich  was  clipped  at  tliis 
time;  both  ears  discharging  on  tenth  day;  losing  weight  steadily,  gavage; 
catarrhal  enteritis;  convulsions  on  fourteenth  day;  jaundice  on  twentieth 
day;  ecchymoses  general,  and  rigidity  of  extremities  and  spine;  death  on 
twenty-first  day. 

CASE  II.     Tedious   labor,  terminated   by   forceps  delivery,   child  weigh- 


DISEASES  AND  INJURIES  OF   THE  NEW-BORN,  47 

ing  714  pounds;  normal  for  first  three  days;  temperature  of  104°  F.  on 
morning  of  fourth  day,  which  was  thought  to  be  due  to  starvation.  Arti- 
ficial feeding  reduced  temperature  to  100.6°  F.,  and  it  was  normal  the 
next  day.  The  cord  dropped  off  on  the  fifth  day,  leaving  a  moist  base.  On 
the  seventh  day  the  temperature  was  104.4°  F.;  listless  and  slow  about 
nursing.  Pus  found  in  umbilical  depression;  pain  on  manipulation  of 
abdominal  wall,  and  some  distension.  Continuous  temperature  until  its 
death,  three  days  later,  when  it  reached  107°  F.  Just  before  its  death 
hands  and  feet  became  cold  and  blue,  changing  to  deep  purple,  the  dis- 
coloration on  the  lower  extremities  extending  to  the  hips. 

INJURIES  TO  THE  NEW-BORN. 

As  a  result  of  prolonged  labor,  pelvic  deformities,  with  instru- 
mental or  manual  delivery  to  overcome  these  conditions,  the  child 
may  sustain  fatal  injuries,  or  injuries  which  may  cripple  it 
for  life. 

High  Forceps  is  a  capital  operation  with  very  serious  results 
in  a  large  percentage  of  cases.  Williams,  in  119  collected  cases 
of  high  forceps,  found  a  maternal  mortality  of  40  per  cent 
and  an  infantile  mortality  of  60  per  cent. 

As  a  result  of  forceps  operation  the  following  injuries  may 
be  named :  Lacerations  of  the  skin  by  the  blades ;  injury  to  eye, 
especially  when  a  fenestrated  blade  is  applied  too  far  up  upon 
the  head;  facial  paralysis;  depressed  cranial  bone,  or  a  frac- 
ture of  the  bones ;  cerebral  hemorrhage  from  rupture  of  vessels 
in  the  meninges  or  brain ;  facial  paralysis  from  pressure  of  the 
tips  of  the  blades  on  the  seventh  nerve. 

Version. — ]May  result  seriously  to  a  living  child.  Among  the 
most  frequent  accidents  are  fractures  of  the  long  bones  of  the 
extremities  and  the  clavicle;  laceration  or  rupture  or  hematoma 
of  the  sternocleidomastoid  muscle ;  fracture  and  depression  of 
the  cranial  bones;  rupture  of  vessels  in  the  meninges  or  of  the 
sinues  in  the  dura;  Erb's  paralysis  from  pressure  on  the 
brachial  plexus  of  nerves;  atelectasis  from  delayed  delivery  of 
the  after-coming  head. 

MASTITIS. 

During  the  first  two  weeks  after  birth  the  child's  breasts  fre- 
quently become  distended  with  milk,  occurring  in  either  sex. 
The  breasts  may  become  tense  and  painful  to  the  touch,  causing 


48 


tHE  DISEASES  OF   CHtLDRElsr. 


restlessness  and  crying.  If  friction  or  pressure  is  used  upon 
them,  a  breaking  down  of  the  gland  tissue  is  apt  to  ensue,  or  an 
infection  follow  which  results  in  a  severe  inflammation,  with 
formation  of  pus. 

Focal  Sjrmptoms. — Continued  enlargement  of  the  breast,  red- 
ness of  the  skin  over  it,  fluctuation,  tenderness  on  manipulation. 


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r^i'Tt/s^ac^-^^^*'^^-'--^^?^. 

Fig.   8. — Starvation  temperature. 

Prognosis. — If  an  abscess  does  not  result,  the  milk  is  soon 
absorbed  and  no  trouble  results,  but  if  an  abscess  forms,  and  an 
incision  is  necessitated,  the  function  of  the  gland  of  a  female 
may  be  impaired  in  later  life. 

Under  aseptic  precautions,  in  suspected  cases,  a  hypodermic 
needle  may  be  inserted  and  the  contents  aspirated  to  learn  the 
presence  or  absence  of  pus. 


DISEASES   AND   INJURIES   OF    THE   NEW-BORN.  49 

STARVATION  TEMPERATURE. 

The  accompanying  charts  indicate  the  condition  which  is  fre- 
quently seen  during  the  first  few  days  after  birth,  the  second 
or  the  third,  as  a  rule,  in  which  there  is  a  rise  in  temperature, 
which  subsides  after  the  administration  of  an  artificial  feeding, 
or  which  will  disappear  as  soon  as  the  milk  appears  in  the 
mother's  breast.  It  is  a  phenomenon  too  infrequently  noticed, 
as  the  temperature  of  but  few  new-born  babies  is  taken. 

Symptoms. — An  apparently  perfectly  healthy  and  .sound  baby 
cries,  sucks  its  fists  and  tugs  at  the  empty  breasts,  and  is  very 
restless ;  its  skin,  mouth  and  tongue  are  hot  and  dry ;  and  prostra- 
tion begins  promptly.  The  temperature  rises  quickly  and  has 
usually  reached  its  maximum  in  a  few  hours. 

Treatment. — In  the  presence  of  a  high  fever  without  other 
definite  symptoms  the  child  should  be  given  an  artificial  feeding, 
if  the  breasts  are  not  secreting,  composed  of  a  weak  modified 
milk  mixture  of  a  formula  approximating  the  following:  Fat, 
1.,  sugar  6.,  proteid  0.50,  3^2  to  1  ounce  at  a  feeding.  The  tem- 
perature should  be  taken  again  in  a  few  hours  to  ascertain  its 
course,  and  if  it  is  declining  the  baby  should  be  fed  regularly 
until  the  milk  comes.  If  it  will  not  nurse,  gavage  may  be  tried 
with  excellent  results. 

CEREBRAL  HEMORRHAGE. 

The  proneness  of  new-born  infants  to  hemorrhages,  has  already 
been  referred  to.  Cerebral  hemorrhages  may  arise  from  the 
vessels  in  the  brain,  meninges  or  dura,  may  be  very  small  in  size 
or  consist  of  large  extravasations.  They  frequently  follow  a 
tedious  or  instrumental  delivery  and  deformed  pelvis  which 
cause  undue  intracranial  pressure.  This  complication  will  be 
referred  to  in  another  chapter. 

TETANUS. 

Synonyms. — Lockjaw,  tnsmus  nascentium. 

Etiology. — Tetanus  is  due  to  the  entrance  of  the  tetanus 
bacillus  into  the  circulation,  its  toxins  exerting  their  effect 
particularly  upon  the  central  nervous  system.  The  bacillus  may 
enter  at  the  umbilicus  or  an  abrasion  of  the  skin  carried  through 


50  THE   DISEASES   OP    CHILDREN. 

the  medium  of  unclean  hands,  dressings,  etc.  The  principal 
habitat  of  the  bacillus  is  in  the  neighborhood  of  stables  and 
stable  yards,  and  dust  and  dirt  from  this  locality  may  convey 
the  infection. 

Pathology. — There  may  not  be  any  characteristic  change  in 
the  tissues  at  the  point  of  entrance  of  the  bacillus,  or  a  slight 
inflammatory  reaction.  The  brain  and  cord  may  show  punc- 
tate hemorrhages  or  larger  extravasations,  as  a  result  of  the  con- 
vulsions. The  internal  organs  are  congested  and  there  are  ser- 
ous exudates  in  the  ventricles  and  cord. 

Symptoms. — In  a  majority  of  cases  the  symptoms  appear 
during  the  first  week  or  ten  days  after  birth,  though  they  may 
occur  any  time  before  the  fourteenth  day.  It  is  rare  dilring  the 
third  week. 

The  child  may  at  first  be  listless  and  show  a  disinclination  to 
nurse ;  there  soon  follows  a  spasmodic  contraction  of  the  muscles 
of  the  lower  jaw,  which  very  soon  becomes  fixed  and  tightly 
closed.  It  is  impossible  to  push  the  nipple  between  the  child's 
gums.  If  liquids  are  poured  into  the  mouth  swallowing  is  im- 
possible, and  the  first  few  drops  passing  the  pharynx  may  cause 
a  reflex  spasm  of  the  pharyngeal  muscles  and  a  general  convul- 
sion. The  child  has  an  anxious,  frowning  look,  between  the 
.spasms,  and  a  more  or  less  general  spasmodic  contraction  of  the 
facial  muscles  during  a  convulsion.  During  a  general  convul- 
sion the  respirations  are  stertorous  and  between,  they  are  hur- 
ried and  superficial.  The  sphincters  of  bladder  and  rectum  are 
relaxed  and  involuntary  passages  are  usual.  As  the  case  pro- 
gresses the  periods  of  rest  between  the  convulsions  are  shorter, 
contractions  begin,  the  spine  becomes  contracted,  arching  back- 
ward, the  opisthotonos  being  at  times  extreme,  the  child  resting 
on  head  and  heels.  The  temperature  is  usually  very  high,  104° 
F.  to  106°  F.  In  the  latter  period  a  convulsion  may  be  induced 
by  touching  the  child,  especially  about  the  face.  Feeding  is 
impossible. 

Prognosis  is  very  grave,  as  nearly  all  cases  die.  The  younger 
the  child  the  more  hopeless  the  case.  Escherich  reports  recov- 
eries. 

Diagnosis. — This   is   usually   easy   and   must  be   made   from 


DISEASES   AND   INJURIES  OF   THE   NEW-BORN.  51 

menin^tis  and  from  the  paralyses  and  contractions  following 
cerebral  hemorrhages  of  the  new-born. 

Treatment. — The  most  favorable  results  can  be  had  from  the 
use  of  the  tetanus  antitoxin,  which,  like  the  diphtheria  anti- 
toxin, gives  the  best  results  the  earlier  it  is  used.  As  in  adults 
the  serum  is  a  better  prophylactic  agent  than  a  curative  one. 
Five  to  ten  cubic  centimetres  of  the  antitoxin  may  be  injected, 
and  repeated  in  from  six  to  eight  hours.  The  subcutaneous 
method  is  recommended,  over  the  injection  into  the  spinal  canal, 
owing  to  the  difficulty  of  performing  the  latter  operation.  The 
influence  upon  the  minds  of  the  family  of  the  lumbar  puncture 
is  very  great,  and  a  fatal  result  of  the  disease  is  attributed  to 
the  puncture  by  the  average  layman. 

Prophylaxis  is  the  chief  treatment,  strict  cleanliness  in  tying 
the  cord  and  its  care  afterward  being  an  absolute  essential. 
Upon  the  appearance  of  the  symptoms,  control  the  convulsions 
if  they  are  severe,  by  inhalations  of  chloroform.  Give  at  once 
the  following  prescription  by  rectum,  using  the  small  bulb  syr- 
inge: 

If  Strontii  bromidi  gr.  v 
Chloralis  hydratis  gr.  ii 
Aquae  distillat  '^i 

M  ft.  Clyster. 

This  may  be  repeated  in  two  or  three  hours  for  its  effect. 
Gavage  should  be  resorted  to  with  tube  introduced  through  the 
nose  in  those  cases  in  which  improvement  is  noted  in  the  con- 
vulsive stage. 

SCLEREMA. 

Etiology. — This  is  obscure,  being  ascribed  as  due  to  sepsis, 
persistent  fetal  circulation;  athrepsia,  especially  that  following 
acute  diarrheal  diseases  and  poor  nourishment.  Two  forms  are 
described,  scleredema  or  the  edematous  form,  and  sclerema  add- 
posum  or  fat  sclerema. 

Pathology.— In  scleredema  the  changes  described  are  an 
edematous  deposit  in  the  skin,  cellular  tissue,  muscles ;  serum 
in  the  peritoneal  and  pleural  cavities;  inflammatory  conditions 
of  the  intestines  and  lungs;  atelectasis;  fatty  liver  and  spleen. 


52  THE  DISEASES  OP   CHILDREN. 

In  the  form  known  as  sclerema  adiposum,  there  is  a  hard- 
ening of  the  tissues,  a  drying  up  of  the  fat  in  them,  the  changes 
in  the  internal  organs  being  much  the  same  as  in  the  other  form. 

Symptoms. — In  scleredema  there  is  a  subnormal  temperature, 
with  dry,  cold  skin.  The  parts  first  affected  are  usually  the 
calves  of  the  legs,  the  thighs,  abdominal  wall  and  if  severe,  then 
the  rest  of  the  body.  The  skin  may  pit  on  pressure,  or  in  the 
more  severe  forms  be  so  tense  as  not  to  be  influenced  by  pressure. 
If  punctured  yellowish  serum,  rather  oily,  exudes. 

In  favorable  cases  the  skin  gradually  resumes  the  normal, 
leaving  wrinkles  over  the  previously  affected  parts.  Desqua- 
mation usually  supervenes. 

In  sclerema  adiposum  the  legs  are  also  the  first  part  affected, 
usually  symmetrically.  It  also  may  involve  the  whole  body, 
except,  as  a  rule,  the  palmar  surfaces  of  the  hands  and  plantar 
surfaces  of  the  feet.  The  skin  feels  doughy,  it  is  closely  adher- 
ent to  the  underlying  tissues.  The  heart  is  weak  and  much 
slower  than  normal,  as  are  the  respirations.  The  temperature 
is  usually  lower  in  this  form,  92°  F.  being  recorded  as  having 
been  reached. 

Duration  is  short  in  both  forms,  though  it  is  usually  much 
more  rapidly  fatal  in  the  latter  form. 

Prognosis  is  very  grave  in  both  forms,  though  recovery  is 
reported  in  both. 

Treatment. — The  first  indication  is  the  restoration  and  main- 
tenance of  the  body  temperature,  which  can  be  done  by  impro- 
vising an  incubator.  External  heat  is  most  important.  Stimu- 
lants are  necessary,  especially  whisky  and  strychnia,  1/200  grain 
of  the  latter,  by  the  mouth  or  subcutaneously  in  a  portion  of  the 
body  unaffected.  Camphor  in  olive  oil  may  be  given  by  hypo- 
dermic in  very  weak  heart  action  with  good  results. 

External  application  of  cod  liver  or  olive  oil,  with  mild 
massage,  is  a  great  help.  Gavage  may  have  to  be  resorted  to  in 
some  cases. 


CHAPTER  IV. 

GROWTH  AND  DEVELOPMENT. 

The   average   weight  for  boy  babies   at  birth  is   about  7i/ij 
pounds,  of  girls  7  pounds.     But  few  babies  weigh  as  much  as  12 


HAMnoCK   AND 

SCALES 

ROLLED 


Fig.    9. — Hammock    scale    (Cooke). 

pounds  at  birth.  During  the  first  week  after  birth  the  child 
loses  in  weight,  frequently  as  much  as  a  pound,  but  upon  the 
advent  of  the  mother's  milk  the  gain  in  weight  is  steady  and 

53 


54  THE   DISEASES   OP    CHILDREN. 

should  be  not  less  -than  4  ounces  a  veek.  Usually  at  the  end  of 
the  third  week  it  has  more  than  regained  its  birthweight.  No 
other  single  method  is  of  such  assistance  in  determining  a  child's 
progress  as  its  weight,  and  a  pair  of  scales  should  be  as  much  a 
part  of  a  nursery  outfit  as  a  baby's  bed.  The  platform  dial 
scale  upon  which  has  been  anchored  a  basket  is  a  very  useful 
one,  as  it  weighs  in  one-quarter  pounds,  but  the  platform,  arm- 
balance  scale  is  much  more  accurate.  The  weighing  is  best 
done  after  a  bath  when  the  child  has  been  dried  ready  for  dress- 
ing.    It  is  thus  weighed  without  clothes  and  with   an  empty 


Fig.    10. — Nursery   scales. 

stomach.  If  the  dial  scale  is  used  the  arrow  can  be  made  to 
start  at  zero  by  the  set-screw  on  the  top  after  the  blanket  has 
been  placed  in  the  basket;  but  if  the  balance  scale  is  used  the 
blanket  must  be  accurately  weighed  and  deducted  from  the  gross 
weight. 

As  a  rule  infants  which  are  deprived  of  normal  breast  milk 
do  not  thrive  as  rapidly  as  those  who  are  nursed  at  the  breast. 
When  a  suitable  formula  of  modified  milk  has  been  provided  the 
gain  is  then  satisfactory. 

"While  it  is  of  great  service  to  the  physician  in  estimating 
the  progress  of  a  child,  to  know  its  weight  from  week  to  week, 
this  regular  weekly  weighing  may  unnecessarily  worry  a  nervous 
mother,  and  some  discretion  must  be  exercised  in  requesting  it. 

The  following  chart,  an  average  taken  from  a  number  of  pub- 


GROWTH   AND    DEVELOPMENT. 


55 


lished  records  of  investigations,  gives  the  growth  of  the  infant 
from  birth  through  childhood. 


Birth 
6  mos. 
12  nios. 
18  mos. 

2  yrs. 

3  yrs. 

4  yrs. 

5  yrs. 

6  yrs. 

7  yrs. 

8  yrs. 

9  yrs. 

10  yrs. 

11  yrs. 

12  yrs. 

13  yrs. 

14  yrs. 

15  vrs. 


j  Boys . 
^  Girls. 
( Boys . 
^  Girls. 
jBoys. 
^Girls. 
jBoys. 
^  Girls. 
^Boys. 
I  Girls. 
( Boys. 
^  Girls. 
( Boys . 
I  Girls. 
jBoys. 
^  Girls. 
]Boys. 
^  Girls. 
( Boys . 
^Girls. 
( Boys . 
^  Girls. 
^Boys. 
I  Girls. 
jBoys. 
^  Girls. 
\  Boys . 
^  Girls. 
( Boys . 
I  Girls, 
poys. 
I  Girls. 
( Boys . 
I  Girls. 
(  Boys . 
)  Girls. 


WEIGHT. 

HEIGHT. 

HEAD 
CIECUM. 

CHEST 
BREADTH 

7.47 

20.1 

13.8 

13.0 

7.13 

19.9 

13.3 

12.4 

16.0 

25.4 

16.5 

16.6 

15.5 

25.0 

16.5 

15.6 

21.2 

29.2 

17.9 

17.9 

20.4 

28.7 

17.9 

18.2 

22.8 

30.0 

18.5 

18.5 

22.0 

29.7 

18.0 

18.2 

28.4 

33.1 

19.1 

19.5 

27.8 

32.7 

18.3 

18.2 

33.5 

36.0 

19.3 

20.1 

31.5 

35.6 

19.0 

19.8 

36.4 

38.6 

19.7 

20.7 

35.1 

38.4 

19.5 

20.5 

41.4 

41.7 

20.3 

21.5 

40.2 

41.3 

19.9 

21.2 

45.1 

44.0 

20.0 

23.2 

43.6 

43.4 

19.8 

22.8 

49.5 

46.1 

20.0 

23.7 

47.8 

45.8 

20.0 

23.3 

54.5 

48.5 

20.5 

24.4 

52.2 

47.8 

20.2 

23.8 

59.8 

50.0 

20.6 

25.1 

57.4 

49.6 

21.2 

24.5 

66.0 

52.0 

20.6 

25.8 

63.0 

51.7 

20.5 

24.7 

71.5 

53.8 

20.8 

27.2 

69.9 

53.8 

20.7 

25.8 

78.8 

55.6 

21.0 

27.5 

80.0 

56.6 

20.9 

26.8 

86.0 

57.8 

21.1 

27.7 

89.9 

58.6 

21.5 

28.5 

97.2 

60.5 

21.3 

28.8 

99.3 

60.3 

21.3 

30.0 

104.1 

62.9 

22.2 

30.5 

107.5 

61.5 

22.0 

31.0 

The  suggestion  of  Holt  that  a  record  blank  or  "progress  re- 
port" be  printed  and  given  to  mothers  when  dismissed  from 
their  piierperium,  which  are  to  be  filled  out  and  mailed  to  the 


56  THE   DISEASES  OF    CHILDREN. 

physician  at  Aveekly  or  bi-weekly  intervals,  is  a  most  excellent 
one.  The  following  chart,  a  modification  of  Holt's,  is  of  great 
service  in  recording  the  progress  of  the  child;  its  weight,  gain 
or  loss;  digestion,  disposition,  food  prescriptions,  etc.  In  the 
card  index  system  it  is  easily  referred  to,  and  a  matter  of  perma- 
nent record.  The  last  three  lines  are  filled  in  by  the  physician 
recording  any  changes  which  may  be  made  in  food  prescriptions, 
if  laboratory  fed,  and  the  formula  if  the  milk  is  modified  at 
home. 

REPORT   ON    PROGRESS    OF 

Xame    Date 19 . .  . 

Weight lb oz.    Gain oz.    Since  last  report 

Loss OZ. 

Stools  avg.  in  24  hours Color Mucus 

Curds Watery Loose Thick 

Flatulency   or   cole  ? 

Appetite :     Is  child  satisfied  ? Is  any  food  left  ? 

Is  the  child  comfortable  and  good  natured  ? 

How  much  does  he  sleep  ? 

Date  of  last   report  ? 

a. F.  S.  P  Cr.     %     Sk.M M.  S 

No  feed Interval Dil Aq Aq.  C 

Each  3 Total  24  hr.  5  


The  child's  first  years  are  usually  divided  as  follows,  early 
infancy  from  birth  to  the  twelfth  month ;  infancy  until  the  com- 
pletion of  dentition,  usually  about  two  and  a  half  years,  child- 
hood from  this  time  until  puberty. 

The  measurements  of  the  chest  and  head  are  given  on  page  55. 
It  can  be  noted  by  reference  to  the  table  that  at  birth  the  head 
is  greater  in  circumference  than  the  chest;  at  the  third  year 
they  are  about  equal,  and  from  this  time  on  the  chest  is  larger. 

The  new-born  infant  should  have  regained  its  birthweight 
shortly  after  the  end  of  the  first  week ;  by  the  end  of  the  second 
week,  gained  2  to  4  ounces;  at  16  weeks  its  birthweight  is  usu- 
ally doubled,  and  at  one  year  of  age  it  is  usually  three  times  its 
birthweight. 

The  most  rapid  growth  of  the  infant  during  the  first  year  is 
in  its  weight.     Its  increase  in  length  in  this  period  is  about 


GROWTH   AND   DEVELOPMENT.  57 

8  inches,  and  after  this  it  is  at  the  rate  of  about  4  inches  a  year. 

Any  serious  interference  in  this  ratio,  approximately,  is  an 
evidence  of  defective  nutrition  as  a  rule,  and  should  receive 
prompt  and  careful  attention.  Schwartz  ^  has  suggested  the 
following  tables  for  calculating  the  weight  and  height  at  differ- 
ent ages : 

Weight  first  twelve  months.  Third  to  seventh  month,  add  10 
to  the  month ;  other  months  add  8  to  the  month. 

Example:     Weight   at    4th   month?       4  +  10=14  lbs. 
Weight  at  10th  month?     10+    8  =  18  lbs. 

Weight  of  a  child  at  any  age.  Multiply  the  age  of  the  child, 
plus  1,  by  5,  and  add  10;  except  for  the  twelfth,  thirteenth  and 
fourteenth  years  add  15,  20  and  25,  respectively. 

Example:     Weight  of  child  at  4  years? 

4+1=5     5X5  =  25     25  + 10 >=i 35  lbs. 
Weight  of  child  at   15th  year? 

15  +  1p=i16     16X5  =  80     80  +  20  =  100  lbs. 

Height  of  a  child  at  any  age.  Up  to  the  sixth  year  multiply 
the  year  by  3  and  add  26,  after  the  sixth  year  multiply  by  2  and 
add  32. 

Example:     Height  of  child  at  4  years? 

4X3  =  12     12  +  26 c=i 38  inches. 

DENTITION. 

The  process  of  eruption  of  the  teeth  through  the  gums  is  den- 
tition. A  child  may  be  born  with  a  tooth  through  the  gum,  but 
these  cases  are  most  rare,  and  the  teeth  very  soon  become  loose 
and  fall  out.  The  first  teeth  are  the  temporary,  deciduous  or 
milk  set,  and  are  composed  of  two  central  and  two  lateral  in- 
cisors, two  canines  and  four  molars  in  each  jaw.  The  teeth 
are  found  in  the  jaw  about  the  sixth  week  of  intrauterine  ex- 
istence. As  nutrition  proceeds  the  crown  is  completed,  the  root 
hardens  and  develops,  and  they  are  forced  outward  through  the 
gums. 

The   eruption   of  the   teeth   is   a  physiological   and   entirely 


1  New  York  Medical  .lourual. 


58 


THE   DISEASES   OF    CHILDREN. 


normal  process,  and  should  not  be  looked  upon  as  the  bugbear 
of  infancy.  It  is  very  easy  to  state  that  any  pathologic  condi- 
tion, especially  gastrointestinal  disturbances,  occurring  during 
the  first  five  months,  are  due  to  the  teeth,  and  not  look  to  tiie 
diet,  for  instance,  as  a  cause  of  the  disturbance. 


'I  NCI  Softs  I 


Fig.   11. — Temporary  and  permanent  teeth. 

Unquestioned  eases  of  disturbance  of  digestion,  vomiting  or 
mild  diarrhea :  or  mikl  but  persistent  cough,  are  seen  during  the 
early  period  of  dentition,  with  more  or  less  prompt  relief  of 
symptoms  when  the  gum  is  penetrated  by  the  tooth.  Cases  in 
which  these  symptoms  are  coincident  with  the  eruption  of  a 
tootb  are  almost  witliout  exception  subjects  of  other  disorders, 
principally  of  nutrition.  ]\Iuch  delayed  dentition  is  usually  due 
to   rachitis.     There    is   usually   an   active    development    of  the 


GROWTH   AND   DEVELOPMENT.  59 

salivary  glands  some  weeks  before  a  tooth  is  cut,  and  there  is  a 
constant  escape  of  saliva  from  the  mouth  during  the  waking 
hours.  The  child  may  be  more  restless  than  usual,  and  bite  upon 
everything  it  can  grasp  with  its  hand. 

It  is  in  those  cases  which  show  some  nervous  symptoms  and 
restlessness  or  which  present  some  of  the  other  symptoms  enu- 
merated, that  the  most  benefit  is  had  from  making  an  incision 
through  the  gums.  This  does  not  retard  the  eruption  of  the 
teeth  through  the  scar  tissue  which  may  form  over  the  tooth,  but 
relieves  the  tension  and  swelling  of  the  gums  and  many  or  all  of 
the  symptoms.  The  child  is  held  upon  the  lap  of  the  nurse, 
who  sits  facing  the  operator.  The  child  sits  with  its  back  to  the 
operator,  and  with  the  nurse  holding  its  hands  its  head  is  lowered 
between  the  knees  of  the  operator  and  there  held.  With  one 
hand  holding  open  the  gums  and  retracting  the  lip,  the  incision 
is  made  directly  over  the  teeth  with  the  other.  It  is  generally 
not  necessary  to  lance  the  gums  over  the  molars,  as  they  usually 
erupt  one  sharp  prong  at  a  time  and  without  symptoms  or  diffi- 
culty. The  first  deciduous  teeth  to  fall  out  are  the  upper  central 
incisors,  as  a  rule,  the  permanent  teeth  very  shortly  afterward 
coming  in.  The  first  milk  teeth  are  lost  usually  at  the  end  of 
the  sixth  year,  the  20  occupying  the  site  of  these  and  are  fol- 
lowed by  the  molars.     The  teeth  usually  appear  as  follows : 

Two  lower  central  incisors,  six  to  nine  months. 

Four  upper  incisors,  seven  to  ten  months. 

Two  lower  lateral  incisors,  12  to  14  months. 

Two  anterior  upper  molars"!     ^_ 

^  ^    •      1  1        ^    12  to  16  months. 

Two  anterior  lower  molars  J 

Two  upper  canines  (eye  teeth)  1     -.n  ^     ^^  ^i 

m       1  •        \\         X.  4.    4.u\    18  to  24  months. 

Two  lower  canmes   (stomach  teeth  J 

Two  upper  posterior  molars^     r.^  ^    or*  xi 

^       ,  ^     ,     .  ,        ^    24  to  30  months. 

Two  lower  posterior  molars  J 

The  permanent  teeth  usually  are  cut  as  follows : 

Four  first  molars,  six  years. 

Four  central  incisors,  seven  years. 

Four  lateral  incisors,  eight  years. 

Four  bicuspids,  eight  and  one-half  to  nine  years. 

Four  bicuspids,  ten  years. 


60  THE   DISEASES   OF    CHILDREN. 

Four  canines,  11  years. 
Four  second  molars,  12  to  13  years. 
Four  wisdom  teeth,  18  to  25  years. 

An  attack  of  acute  illness,  just  at  the  time  of  the  dentition, 
may  seriously  impair  the  life  of  the  tooth. 

CASE.  Mother  nursing  infant  of  three  months  developed  a  severe 
typhoid  fever.  Baby  removed  at  once  and  put  on  modified  milk.  In  ten 
days  or  two  weeks  afterward  child  developed  a  typical  attack  of  typhoid 
fever,  which  ran  a  mild  but  usual  course.  Very  soon  after  the  subsidence 
of  the  fever  she  cut  her  first  teeth.  She  rapidly  began  to  gain  in  weight, 
but  a  black  line  developed  on  the  upper  central  incisors.  This  deepened 
and  finally  the  teeth  broke  oflf  through  the  line,  short  with  the  gums,  and 
no  other  teeth  have  displaced  them,  though  the  child  is  now  four  years 
of  age. 

The  deciduous  or  temporary  teeth  should  be  cared  for  with 
the  same  routine  as  the  permanent  set.  They  should  be  brushed 
twice  daily  with  a  soft  tooth-brush  or  cotton  mop,  and  regularly 
inspected  by  a  competent  dentist  for  any  imperfections  indi- 
cating softening.  Nothing  so  completely  upsets  the  nervous 
equilibrium  of  a  child  as  the  toothache,  and  should  always  be 
prevented. 

Timely  and  proper  removal  of  the  deciduous  teeth  may  pre- 
vent erratic  cutting  of  the  permanent  teeth,  which  later  will 
have  to  be  straightened.  Thumb  and  finger  sucking,  and  the 
pernicious  use  of  the  ' '  comforter, ' '  or  rubber  nipple,  as  a  quieter 
or  pacifier,  is  a  frequent  cause  of  deformities  of  the  arch  and  dis- 
placement of  the  teeth. 

Hutchinson's  teeth  are  due  to  congenital  syphilis.  The  upper 
central  incisors  are  peg  shaped  and  notched,  with  irregular 
ragged  surfaces. 

MENSTRUATION. 

Menstruation  usually  begins  in  this  climate  between  the  thir- 
teenth and  fifteenth  years  of  age.  In  174  girls,  inmates  of  the 
Masonic  Widows'  and  Orphans'  Home,  the  following  were  the 
ages  recorded  for  the  beginning  of  menstruation : 


GROWTH   AND   DEVELOPMENT.  61 

1 1  years 2 

12  years 18 

13  years 47 

14  years 71 

15  years 33 

16  years 3 

174 

It  was  usual  for  these  children  to  menstruate  once,  perhaps 
twice,  then  miss  for  several  months,  and  begin  again  and  with 
regularity.  Very  frequently  one  month,  occasionally  two 
months,  were  skipped  in  a  year,  without  apparent  cause.  No 
special  season  was  noted  for  this  to  occur.  When  more  than 
three  months  were  missed  after  regular  periods  had  become 
established,  attention  was  given,  and  a  few  weeks'  tonic  treat- 
ment usually  resulted  in  its  re-establishment. 


CHAPTER  V. 

METHODS  OF  EXAMINATION. 

Physical  examination  in  pediatrics  is  our  chief  diagnostic  aid, 
and  all  of  the  known  methods  should  be  employed:  inspection, 
palpation,   auscultation,   mensuration   and  percussion,   chemical 


Fig.    12. —  1,    Axillary   region;    2,    Infra-axillary   region. 

analyses  of  secretions  and  excretions,  and  microscopic  examina- 
tion of  serum,  blood,  excretions  and  exudates,  etc.  The  value  of 
the  information  obtained  from  mother  and  nurse  should  not  be 
minimized,  but  one  should  not  be  influenced  by  misleading  and 
irrelevant  statements. 

62 


METHODS   OF    EXAMINATION. 


63 


A  child  should  always  be  carefully  inspected  as  it  lies,  espe- 
cially if  asleep ;  its  position ;  color ;  respiration,  character  and 
frequency ;  dilatation  of  the  alas  nasi ;  temperature  of  hands  and 
feet. 

Diplomacy  yields  best  returns  in  a  physician's  interview  with 
a  child.  If  you  once  obtain  its  confidence  the  rest  is  easy.  The 
child  may  be  nervous,  cross  and  irritable ;  will  cry  when  touched ; 
it  mav  be  almost  vicious  in  its  resistance  to  examination.     Each 


p 

^        1 

f 

3 

f 

\  1 

4 

Jl 

sT 

J 

%• V 

k-^N 

N 

- 

-  ■  ^_ 

Fig.  13. — 1,  Supra-clavicular;  2,  Cla- 
vicular; 3,  Infra-clavicular;  4,  Mam- 
niarj  ;  5,  Hypochondriac ;  6,  Epigas- 
•"!<•:  7.  Sternal;  8,  Umbilical;  9, 
Hypochondriac. 


Fig.  14. — Posterior  Region.s  of  Chest — ■ 
1,  Inter-scapular;  2,  Supra-scapular; 
3,  Scapular;  4,  Infra-scapular;  5, 
Lumbar. 


child  is  an  individual,  and  no  method  of  approach  will  suffice  in 
two  successive  cases. 

Too  much  emphasis  cannot  be  laid  on  the  importance  of  care- 
ful history  taking  and  recording  the  findings  in  every  case. 
This  is  best  done  on  suitable  blanks  which  can  be  filled  out  at 
the  bedside,  and  filed  in  card  index  systems.  A  daily  resume 
of  symptoms  and  treatment  are  recorded  and  filed  with  the  first 
chart.  Previous  illness,  dentition,  food,  bowels,  and  the  symp- 
toms and  course  of  present  illness  are  carefully  recorded,  and 


64  THE   DISEASES   OF    CHILDREN. 

a  daily  record  blank  used  afterward  in  connection  with  the 
ease.  A  blank  used  by  the  author  for  the  first  history  is  shown 
here: 

Name 

Add     

Ser.     To    


r  Vigorous . 
J  Respir.  .  . 
(  C'onvuls. . 
Wt.   at   birtli Breast  fed Diet  since . .  . 


Prem (  Duration     Cond.  birth 

Born Term Labor  1  Instrument 


Wt 

Teeth    Ist    

Crept Walked 

Measles Pertussis Scarlat Diphth Grip 

Tonsil Otitis Croup Bronch Pneumon . 

Nervous   sys Sleep Adenoids .  .  . 


Note  the  child  as  it  awakens,  whether  bright,  quiet,  peevish  or 
crying;  size  of  its  pupils,  color  of  skin,  etc.  A  child  cries  for 
some  cause  as  a  rule.  Kilmer  gives  the  following  11  causes  for 
a  child 's  crying : 

1,  because  it  is  hungry;  2,  because  it  is  in  pain;  3,  because  it 
is  thirsty ;  4,  because  it  wants  attention ;  5,  it  is  sleepy ;  6,  its 
napkin  is  wet;  7,  it  is  tired  lying  in  one  position;  8,  it  is  friglit- 
ened ;  9,  it  is  exhausted ;  10,  it  is  crying  from  temper ;  11,  it  is 
uncomfortable,  clothes  wrinkled,  etc.  It  must  be  remembered 
that  a  normal  healthy  child  does  not  cry  from  choice. 

Inspection  should  include  a  personal  view  of  the  napkins,  es- 
pecially if  there  has  been  any  variation  from  normal  in  the  evac- 
uations. No  description  by  nurse  or  mother  is  adequate  to  con- 
vey the  real  character  of  an  action. 

It  should  be  determined  whether  the  sight  of  the  child  is 
normal  or  impaired,  if  the  pupils  are  equal,  contracted,  dilated 
or  fixed.  The  presence  of  nystagmus,  or  side  to  side  movements 
of  the  eyeball  is  noted.  If  the  child  is  able  to  be  up,  the  char- 
acter of  the  gait  should  be  noted.  The  reflexes  also  should  be 
noted.  The  chief  one  is  the  knee  reflex,  obtained  by  tapping  the 
tendon  below  the  patella  while  supporting  the  thigh  and  allow- 
ing the  leg  to  hang  naturally. 


METHODS   OF    EXAMINATION.  65 

Kernig's  Sign. — The  child  lying  upon  its  back  with  thigh 
flexed  half  way  upon  the  abdomen,  the  leg  partly  flexed  on  the 
thigh,  the  leg  cannot  be  extended. 

Babinski's  Reflex. — With  leg  extended  and  slight  irritation 
of  the  plantar  surface  of  the  foot  the  great  toe  is  fully  extended, 
and  the  other  toes  partly  flexed.     This  reflex  is  noted  specially 


Fig.    15. — Position   for   taking   rectal   temperature. 

in  tubercukr  meningitis,  though  authorities  differ  as  to  its  value 
as  a  diagnostic  sign. 

Sach's  Sign  of  Chorea. — The  child,  standing  before  the  exam- 
iner, is  a.sked  to  repeat  a  certain  sentence,  and  in  the  effort  to 
do  so  there  is  a  decided  tremor  of  the  hands,  which  are  held  in 
those  of  the  examiner. 

The  cry  of  a  child  is  usually  characteristic.  In  cerebral  affec- 
tions the  cry  is  shrill  and  sudden ;  in  affections  of  the  larynx  it 
is  hoarse,  brassy,  strident;  with  middle  ear  inflammations  it  is 
eontinuou.s  and  shrill  and  accompanied  with  pulling  at  the  ear 


66  THE  DISEASES  OP   CHILDREN. 

affected;  in  colic  the  child  cries  loudly  and  intermittently,  and 
continuously  flexes  and  extends  its  legs  and  thighs. 

Temperature. — As  already  stated  the  temperature  of  the  child 
during  the  first  year  is  usually  between  99°  and  99.5°  F.  An 
infant's  temperature  should  always  be  taken  in  the  rectum.  If 
the  mother  has  a  thermometer  hers  should  be  used,  and  if  not 
the  physician  should  carry  two,  one  for  use  in  the  rectum  only. 
The  child  may  be  held  upon  the  nurse's  lap  lying  upon  its 
abdomen,  legs  hanging  down.  With  napkin  off;  the  thermom- 
eter, well  anointed,  is  carefully  passed  into  the  rectum  and 
allowed  to  remain  for  two  minutes.  Half-minute  thermometers 
are  not  reliable.  The  child  may  be  placed  upon  its  side,  on  the 
nurse's  lap  or  in  bed,  with  thighs  flexed,  but  under  no  circum- 
stances should  the  thermometer  be  inserted  in  the  rectum  with 
the  child  lying  on  its  back  with  legs  and  thighs  flexed,  as  it  may 
raise  the  hips  from  the  bed  and  break  the  thermometer. 

After  taking  the  temperature  the  thermometer  should  be  care- 
fully washed  with  soap  and  water  and  placed  in  alcohol  for  a 
moment.  I  have  had  some  success  with  the  clean  shield  rubber 
covering  to  the  thermometer,  which  is  thrown  away  as  soon  as 
used.  The  possibility  of  transmission  of  infection  in  girl  babies 
of  vulvovaginitis  should  be  borne  in  mind.  Groin  or  axillary 
temperature  in  a  child  is 'always  unreliable. 

I  saw  a  child  in  consultation,  ill  with  pneumonia,  and  from 
the  extent  of  the  consolidation  was  surprised  at  the  temperature 
recorded  being  102.5°  F.,  it  having  been  taken  in  the  axilla.  I 
requested  it  taken  in  the  rectum  and  found  it  105°  F.,  which 
was  more  in  keeping  with  the  other  symptoms. 

Another  case  recently  occurred  in  which  the  rectal  tempera- 
ture in  a  suspected  typhoid  was  recorded  as  97°  F.,  with  every 
indication  of  fever.  A  change  of  thermometers  showed  it  to 
be  102°  F.  Examination  of  the  first  one  revealed  the  fact  that 
it  was  not  self-registering,  the  mercury  falling  into  the  bulb  as 
soon  as  it  was  removed  from  the  rectum.  These  things  must 
be  borne  in  mind. 

The  throat  of  every  sick  child  should  be  carefully  inspected. 
The  child  is  held  facing  a  strong  natural  or  artificial  light,  with 
back  to  the  right  shoulder  of  the  nurse,  who  holds  the  child's 


METHODS   OF   EXAMINATION. 


67 


hands.  The  examiner  with  his  left  hand  holds  the  head  and 
with  the  right  depresses  the  tongue  with  spoon  or  tongue  de- 
pressor, and  a  quick  view  of  the  fauces,  tonsils  and  uvula  is 
obtained.  Young  infants  are  usually  not  frightened  by  a  head 
mirror,  though  older  children  may  be  unless  its  use  is  explained 
to  them.     Owing  to  the  fact  that  the  tongue  is  high  in  infants 


Fig.    16.. 


-Examination    of    throat    by    direct    illumination.      Note    position    of    nurse's 
hands,    holding    patient's    head    and    hands. 


and  the  soft  palate  and  tonsils  relatively  low  down,  it  is  oc- 
casionally difficult,  in  them,  to  get  a  good  view  of  the  throat. 

The  importance  of  this  examination  cannot  be  too  forcibly 
emphasized,  as  frequently  severe  attacks  of  diphtheria  may  de- 
velop without  any  pain  or  discomfort  or  inability  to  swallow 
being  complained  of.  The  use  of  the  wooden  tongue  depressor, 
which  is  thrown  away  after  using,  is  recommended  instead  of 
metal  tongue  depressor  or  spoon. 

The  mucous  membrane  of  the  mouth,  cheeks  and  lips  should 
be  inspected  for  the  presence  of  the  buccal  eruption  of  measles 


68 


THE   DISEASES   OP    CHILDREN. 


(Koplik),  which  is  referred  to  under  another  chapter,  or   for 
the  presence  of  ulcers  or  deposit  of  thrush  or  sprue. 

The   tongue   is  inspected   and  its   general   condition  noted; 


Fig.    17. — Tongue    depres.sor    handle    with    removable    wooden    depressors. 

whether  the  frenum  linguaB  is  short  and  inhibits  the  range  of 
motion;  if  it  is  dry,  coated,  flabby,  and  shows  the  imprint  of 
the  teeth;  if  it  presents  the  characteristics  of  the  strawberry- 
tongue  of  scarlet  fever,  or  if  ulcers  are  present  at  any  place  on  its 
surface. 

Examination  of  the  middle  ear  is  a  procedure  too  frequently 


2        3 

Fig.   18. — Ear  specula. 

neglected  by  the  practitioner.  IMany  cases  of  unexplained  fever 
of  some  duration  in  children  can  be  cleared  up  by  an  inspection 
of  the  drum  membrane.  A  bulging  congested  drum  means 
middle  ear  trouble.  An  inspection  is  made  through  a  small 
size  ear  speculum  (the  lobe  of  the  ear  being  drawn  down,  as 
suggested  by  Dr.  Jas.  F.  McKernon  of  New  York),  by  reflected 


METHODS   OF   EXAMINATION.  69 

light  from  a  head  mirror.  The  child  is  held  in  the  nurse's  lap, 
the  unaffected  side  against  the  breast  of  the  nurse,  her  hand 
supporting  the  head  and  with  the  child's  arras  and  hands,  held 
by  a  sheet,  wrapped  around  the  body.  With  the  light  behind 
the  nurse's  head,  and  unobstructed  view  of  the  canal  and  the 
drum  can  be  had  by  reflected  light. 

The  nose  should  receive  attention,  as  much  may  be  found 
here  to  cause  discomfort  if  not  symptoms.  The  child  is  sup- 
ported much  as  for  a  throat  examination,  with  chin  elevated 
and  a  good  view  of  the  entrance  to  each  nostril  obtained. 

Hypertrophied  turbinates  frequently  encroach  on  the  space 
of  the  nostril,  especially  when  there  is  an  acute  coryza.  Con- 
cretions of  dried  discharge  also  may  have  to  be  removed  before 
a  view  can  be  had.  Anointing  with  vaseline,  by  means  of  a 
cotton-protected  swab,  gives  great  comfort  in  these  cases.  The 
habit  of  older  children  of  putting  foreign  bodies,  as  shoe  but- 
tons, beans,  etc.,  in  the  nostril  and  ears  should  be  borne  in  mind. 
I  recently  removed  a  foot  of  a  small  china  doll  from  the  nose 
of  a  two-year-old  child,  experiencing  some  difficulty  in  getting 
a  firm  hold  of  it  with  a  forceps. 

The  skin  should  be  carefully  examined  for  eruptibns,  and  at 
this  time  the  child's  clothes  must  be  entirely  removed.  Enlarge- 
ment of  the  superficial  glands  must  be  looked  for,  axillary,  post- 
cervical,  submaxillary,  epitrochlear  and  inguinal. 

Palpation. — By  palpation  of  the  head  the  condition  of  the 
fontanelles  can  be  ascertained,  craniotabes  located,  if  present, 
and  enlarged  glands  in  the  occipital  and  pvstcervical  region 
found.  Palpation  of  the  chest  with  a  warm  hand  on  each  side 
of  the  anterior  surface,  then  the  posterior  should  be  done  to  as- 
certain presence  or  absence  of  ronchi  or  rattles. 

The  ribs  should  be  examined  for  beading  and  the  epiphyses 
of  the  long  bones  for  enlargement.  The  lower  abdomen  and 
inguinal  region  should  be  palpated  for  hernia,  and  the  scrotum 
for  hydrocele,  hernia  or  undescended  testicle. 

The  frequency  of  the  heart  beat  can  be  determined  by  palpa- 
tion of  the  apex  beat,  or  feeling  the  pulse  at  the  wrist,  temple, 
groin  or  ankle.  Its  character  can  best  be  learned  by  palpation 
of  the  radial  artery  at  the  wrist.     The  frequency  of  the  heart 


70  THE   DISEASES   OF    CHILDREN. 

can  also  be  determined  by  auscultation  over  the  apex,  or  inspec- 
tion of  the  precordial  region. 

The  abdomen  should  be  carefully  palpated  to  ascertain  the 
presence  of  tumors  or  marked  glandular  enlargement ;  the  mus- 
cle guard  over  an  inflamed  appendix ;  an  enlarged  liver  or 
spleen.  An  enlarged  liver  may  be  determined  jalso  by  percus- 
sion, but  an  enlarged  spleen  only  by  palpation.  The  presence  of 
underlying  distended  intestine  prevents  percussion  from  being 
of  value  in  investigating  the  spleen.  An  enlarged  kidney  may 
be  diagnosed  by  abdominal  palpation. 

Rectal  palpation  is  of  great  service  in  diagnosticating  sus- 


Fig.    19. — Bowles   stethoscope   with   small    chest   piece. 

pected  cases  of  intussusception.  This  should  be  done  with  the 
utmost  gentleness.  Inspection  of  the  rectum  for  fissure  should  be 
made  whenever  a  child  cries  with  the  passage  of  his  movements, 
especially  if  there  is  any  blood  with  the  action. 

With  patient  on  a  table,  lying  on  its  face,  the  spine  is  in- 
spected and  palpated.  If  local  bone  changes  (Pott's  disease) 
are  suspected  the  examination  includes  an  effort  to  locate  rigid- 
ity. 

Auscultation  of  the  chest  is  the  most  important  aid  to  diag- 
nosis of  diseases  located  there. 

A  complete  auscultation  of  the  chest  cannot  be  made  without 
the  aid  of  a  stethoscope,  either  the  binaural,  bell  stethoscope 
with  small  chest  piece,  or  the  Bowles  stetho.scope  with  the  small 
chest  piece.  The  child  should  be  held  so  high  that  the  examiner 
does  not  have  to  bend  over,  thus  compressing  his  abdominal 
vessels,  and  causing  a  flushing  of  the  face  and  ringing  in  the 
ears.  It  may  either  be  held  on  the  nurse's  shoulder  for  exam- 
ination of  the  back,  or  face  down  upon  the  nurse's  lap.  Auscul- 
tation of  the  axillary  region  in  a  child  with  the  ear  is  impossible. 
I  have  seen  one  case  of  deep-seated  pneumonia  with  only  one 
spot  the  size  of  a  25-cent  piece  showing  bronchial  breathing,  and 


METHODS   OF    EXAMINATION, 


71 


this  was  located  in  the  extreme  upper  portion  of  the  axilla  where 
the  ear  could  not  possibly  have  been  placed.  Then,  too,  the  ear 
covers  too  much  space  and  it  is  impossible  to  localize  a  small 
area  of  consolidation. 

As  the  auscultation  is  proceeded  with  comparison  should  be 


Fig.  20. — Position  for  auscultation  of  back. 

made  of  the  two  sides  at  exactly  corresponding  points.  It  should 
be  remembered  that  the  child's  chest  wall  is  thin  and  is  a  better 
conductor  of  sound  than  an  adult's,  the  bronchial  tissue  is  greater 
in  proportion  than  the  vesicular,  hence  the  respiratory  sounds, 
especially  expiration,  will  be  much  higher-pitched  than  the 
adult's.  In  fact,  when  listening  to  a  child's  lungs,  it  is  well  to 
forget  the  sounds  in  an  adult's  chest,  they  are  so  different. 

The  sound  over  the  upper  third  of  the  sternum  and  along  th^ 
second  and  third  interspaces  is  quite  bronchial  in  character,  es- 


72 


THE   DISEASES   OF    CHILDREN. 


pecially  on  the  right  side,  because  of  the  larger  size  of  the  right 
primary  bronchus  and  its  angle  at  this  point,  allowing  a  larger 
volume  of  air  to  enter  this  side.  This  is  true  also  over  the  inter- 
scapular spaces. 

Auscultation  of  the  heart  should  be  systematic,  listening  over 


Fig.   21. — Auscultation  of  chest.      Comfortable  position.      Bowles   stethoscope. 

the  apex,  the  base,  and  right  second  intercostal  space,  and  if 
murmurs  are  present  they  should  be  traced  and  located. 

Percussion. — Percussion  over  the  chest  may  be  performed 
with  the  finger  as  the  pleximeter,  and  a  percussion  hammer,  or 
with  the  index  and  second  fingers  of  one  hand  as  the  hammer. 
The  pleximeter  finger  should  be  placed  the  same  on  each  side,  if 
on  the  second  rib  on  one  side  it  must  be  similarly  placed  on  the 
other,  to  obtain  a  comparison  of  sound.  In  percussing  over  the 
posterior  wall,  the  presence  of  the  liver  on  the  right  side  under 
the  ninth  rib  must  be  remembered,  and  not  mistake  the  absence 
of  resonance  for  consolidation  or  exudate  in  the  pleural  cavity. 
The  area  of  dulness  over  the  heart  can  be  easily  determined  by 
superficial  percussion.     On  deep  percussion  in  this  area,  there 


METHODS   OF    EXAMINATION.  73 

is  apt  to  be  transmitted  resonance  from  underlying  lung  tissue. 

Mensuration. — This  is  a  valuable  aid  in  diagnosis.  A  tape 
on  a  spring  in  a  case  which  will  roll  up  on  pressing  a  release 
button  is  most  satisfactory.  The  metal  tape  bearing  the  metric 
measurements  on  one  side  and  English  on  the  other  is  a  very 
serviceable  one,  but  the  greatest  objection  is  the  chill  which  it 
causes  when  brought  in  contact  with  the  skin. 

In  hydrothorax  or  pneumohydrothorax,  the  tape  is  of  the 
greatest  service  in  estimating  the  amount  of  effusion.  In  en- 
largement of  the  joints  it  is  an  assistance,  also  in  ascertaining  the 


Fig.    22. — Stanton's    percussion    hammer. 

presence  or  absence  of  shortening  of  the  lower  extremities,  and 
of  atrophy  following  infantile  paralysis  particularly.  In  mak- 
ing this  measurement  the  comparison  of  the  two  sides  is  taken 
from  the  anterior  superior  spinous  processes  of  the  ilium  and 
the  internal  malleolus  of  the  tibia.  The  measurement  from  the 
umbilicus  as  the  fixed  point  is  relative  only. 

A  useful  tape  in  comparing  the  expansion  of  the  two  sides 
is  made  by  sewing  together  two  tapes  at  1  inch  end,  this  junction 
being  held  upon  the  spine  as  deep  inspiration  is  taken. 

The  comparative  measurement  of  the  head  and  chest  is  of 
value  also.  The  circumference  of  the  head  is  taken  around 
the  middle  of  the  forehead  and  over  the  parietal  bosses,  and 
around  the  nipples  for  the  chest. 

Measurement  of  the  height  of  the  child  should  be  regularly 
made  and  recorded  to  ascertain  if  its  growth  is  progressive  and 
regular. 


CHAPTER  VI. 
THERAPEUTICS  OF  INFANCY  AND  CHILDHOOD. 

There  should  always  be  a  clear  indication  for  medication  in 
children,  and  no  remedy  employed  without  the  indication  is 
present.  Children  respond  readily  to  therapeutic  measures,  and 
this  should  be  borne  in  mind  in  dosage. 

Young's  method  of  figuring  the  dose  of  a  given  medicine  for 
a  child  is  as  follows:  Add  12  to  the  age  of  the  child  and  divide 
the  age  by  this  sum,  which  will  give  the  proportionate  quantity 
of  the  adult  dose. 

Example:     If  the  age  of  the  child  is  two  years: 

2-1-12  =  14      2    (the  age  of  the  child)  -=-  14^^14  or 
1,^  the  adult  dose. 

Cowling's  Rule. — Divide  the  age  of  the  child  at  its  following 
birthday  by  24,  the  result  being  the  proportionate  adult  dose  for 
the  child. 

Example:     If   the    child    is    two    years    old,    2 -^  24  =  %4    or   1^2   the 
adult  dose. 

No  medicine  should  be  given  a  child  under  three  years  of 
age,  in  pill  form,  owing  to  the  possibility  of  the  pill  being  aspi- 
rated into  a  bronchus.  It  is  a  good  plan  to  teach  children  to 
swallow  pills  by  making  a  mass  of  bread,  as  much  that  is  disa- 
greeable to  the  taste  can  be  administered  in  this  form. 

Powders  are  not  well  taken  by  children,  and  should  either  be 
dissolved  or  suspended  in  a  watery  solution  or  in  an  emulsion. 
If  a  powder  is  given  dry  it  is  very  apt  to  gag  the  child  as  it  gets 
in  the  mouth  or  some  of  it  may  be  aspirated  into  the  larynx  and 
cause  violent  coughing. 

Enemata  are  as  a  rule  well  borne.  If  nutrient,  they  should 
be  given  half  high  and  never  in  very  large  quantities.     Two 

74 


THERAPEUTICS   OP   INFANCY   AND    CHILDHOOD.  75 

ounces  is  as  much  as  will  be  taken  care  of  as  a  rule,  and  they 
should  not  be  repeated  too  frequently.  Nutrient  enemas  should 
be  predigested  as  the  bowel  at  this  point  will  absorb  but  not 
digest.  Owing  to  the  loose  mesentery  of  the  sigmoid  flexure, 
and  the  relative  greater  length  of  this  portion  of  the  bowel  a 
child  requires  a  larger  quantity  of  fluid  for  purposes  of  evacua- 
tion  than  is  usually  given.  The  pressure  of  the  fluid  in  the  bag 
should  not  be  very  great,  the  bag  not  being  more  than  3  feet 
above  the  patient.  The  Davidson 
syringe  should  never  be  used  on  an 
infant.  It  is  impossible  to  keep 
this  kind  of  syringe  clean,  and  one 
cannot  gauge  the  amount  of  pres- 
sure exerted  on  the  resistent  bowel. 

_,,  <•    ,1        1  •    1  •  Fig.   23. — Rubber  bulb  syringe. 

The  use  of  the  high,  copious  enema 

for  the  purpose  of  reducing  an  intussusception   is  a  remedy 

which  if  used  at  all  should  be  used  with  the  greatest  caution. 

Suppositories  are  efficient  and,  if  not  too  large  or  too  often 
repeated,  can  be  used  as  a  means  of  medication  or  to  evacuate 
the  bowel.  For  the  latter  purpose  the  long  glycerine  pencil 
is  very  practical  and  very  efficient.  In  writing  a  prescription 
for  a  suppository  directions  should  always  be  given  that  they 
be  small. 

Inhalation. — In  older  children  much  good  can  be  accom- 
plished by  a  croup  kettle  or  steam  atomizer.  The  small  steam 
atomizer  is  placed  at  the  side  of  the  bed  and  a  sheet  so  arranged 
as  to  cover  three  sides  of  the  bed ;  in  this  way  the  child  con- 
stantly breathes  moist  air,  which  can  be  either  with  or  without 
a  medicament.  Benzoin  is  a  very  soothing  remedy  and  may 
be  added  to  the  water  in  the  atomizer. 

In  older  children  the  inhalation  can  be  given  by  making  a 
paper  cornucopia  to  the  top  of  a  pitcher  or  Mason  jar  holding 
hot  water.  The  face  is  held  over  this  and  deep  inhalations  taken 
of  the  plain  or  medicated  vapor. 

In  spasmodic  croup,  or  true  croup  (diphtheria),  especially 
when  a  tube  is  worn  in  the  latter,  the  moist  air  is  of  the  great- 
est help. 

Gargles. — May  be  employed  in  older  children  when  indicated. 


76  THE   DISEASES   OF    CHILDREN. 

A  child  has  to  be  taught  to  gargle,  as  a  rule,  and  usually  in  a 
few  attempts  will  succeed. 

Hypodennoclysis. — In  certain  conditions  where  there  is  a 
septic  condition  or  a  marked  collapse  from  any  acute  or  wasting 
disease,  this  method  of  treatment  yields  excellent  results. 
Enterocylsis,  referred  to  elsewhere,  especially  by  the  continuous 
method,  is  of  great  service  also. 

In  hypodermoclysis,  a  normal  salt  solution,  approximately 
one  teaspoonful  of  salt  to  a  pint  of  distilled  or  filtered  water, 
is  injected  into  the  cellular  tissue  of  the  skin.  These  injections 
should  be  at  a  temperature  of  100°  F.,  and  in  quantities  not 
to  exceed  40  to  50  cc.  at  a  time.  Careful  sterilization  of  the 
needles  and  apparatus,  and  of  the  skin  should  be  obtained.  It 
can  be  given  with  a  fountain  syringe,  or  a  large  antitoxin 
syringe,  such  as  were  formerly  used  for  the  injection  of  diph- 
theria antitoxin. 

Calomel  Vapor  Inhalations. — A  tent  is  made  in  the  same  way 
as  for  steam  medication,  the  steam  started  and  10  grains  of 
calomel  sublimed  in  the  tent,  its  fumes  being  added  to  the  steam. 
The  calomel  can  be  heated  in  a  spoon  held  over  a  candle  or 
alcohol  lamp,  or  in  specially  devised  sublimers.  This  form  of 
treatment  was  used  formerly  more  frequently  than  of  late,  espe- 
cially in  diphtheria  affecting  the  larynx. 

Medicinal  Antipyretics  should  be  used  in  children  with 
great  caution,  this  being  specially  true  of  the  coal-tar  products, 
antipyrine,  acetanilid,  antifebrine  and  phenacetine.  Children 
bear  hydrotherapeutic  measures  very  well  indeed,  and  these 
should  be  used  to  the  exclusion  of  the  medicinal  antipyretics  in 
all  forms  of  hyperpyrexia.  If  it  is  necessary  to  give  them,  the 
use  of  caffeine  at  the  same  time  is  advocated. 

Stimulants  are  well  borne  as  a  rule,  aleoliol  in  some  form ; 
strj^chnia,  nitroglycerine,  sparteine,  digitalis,  all  being  well 
borne  by  children.  Alcohol  in  certain  conditions  is  the  best 
form  of  stimulant,  as  in  the  crisis  of  lobar  pneumonia,  late  in 
typhoid  fever,  diphtheria  and  the  exanthemata.  It  should  be 
well  diluted,  at  least  1  to  6  or  8  parts  of  water,  and  if  whisky 
is  used,  a  good  straight,  bottled  in  bond,  article  should  be  in- 
sisted upon.     Do  not  begin  the  use  of  alcohol  in  the  beginning 


THERAPEUTICS   OF   INFANCY   AND    CHILDHOOD.  77 

of  any  illness  and  not  at  all  until  there  is  a  positive  indication 
for  it.  It  may,  under  conditions  where  the  stomach  will  not 
retain  it,  be  given  by  the  rectum,  but  in  larger  quantities  and 
the  same  dilution.  Brandy  will  often  be  tolerated  when 
whisky  will  not. 

Camphor  is  a  diffusible  stimulant,  and  may  be  used  by  hypo- 
dermic injection  in  olive  oil,  J  or  1  grain  in  20  drops  of  olive 
oil. 

Anodynes. — Children  are  peculiarly  susceptible  to  anodynes, 
and  they  should  be  given  with  great  caution.  Opium,  in  any 
form,  should  never  be  given  mixed  with  other  drugs  in  a  pre- 
scription. It  can  be  given  at  the  same  time,  but  added  to  the 
mixture  at  the  time  of  giving.  In  this  way  a  relatively  large 
dose  can  be  given  as  a  rule.  Chloral  is  also  well  borne  and  can 
be  given  by  the  stomach  or  bowel. 

Counter  Irritants  are  easy  of  application  owing  to  the  deli- 
cateness  of  the  child's  skin.  Mustard,  turpentine,  chloroform, 
in  the  form  of  sinapisms  or  liniments ;  iodine  must  be  used  with 
caution  to  guard  against  blistering.  Blisters  are  easily  raised 
when  desired  by  cantharides  in  form  of  plaster  or  collodion. 

Weak  mustard  plasters  in  my  hands  have  been  of  greater 
service  than  a  strong  mixture.  One  part  of  mustard  to  6  or 
8  parts  of  flour  is  very  efficient  and  soothing.  In  bronchitis, 
bronchopneumonia,  pleurisy  and  intercostal  neuralgia  the  appli- 
cation of  a  mustard  plaster  is  of  the  greatest  efficiency. 

The  Bath. — The  bath  is  a  most  important  and  useful  means 
of  combating  certain  symptoms  in  children.  It  is  the  most 
important  antipyretic  measure,  and  if  children  are  early  taught 
to  enjoy  the  bath  and  are  not  frightened  by  being  plunged  into 
too  cold  water,  it  will  always  be  a  pleasure  to  them  to  be  bathed. 

A  bath  thermometer  should  be  a  part  of  the  equipment  of 
every  nursery,  and  the  temperature  of  the  water  accurately 
taken.  Do  not  use  the  child  as  thermometer,  "if  the  water  is 
too  cold  the  skin  turning  blue,  and  if  too  hot  the  skin  turning 
red."  When  used  as  an  antipyretic  the  water  should  at  first 
be  about  95°  F.  and  cooled  to  75°  F.  or  80°  F.,  according  to 
its  effect  on  the  child.  The  tub  should  be  large  enough  to  allow 
the  child  to  recline,  its  head  supported  by  the  arm  of  the  mother 


78  THE  DISEASES  OP   CHILDREN. 

or  nurse.  If  the  bath  is  given  in  a  porcelain  tub,  a  bath  towel 
is  laid  on  the  bottom  so  the  child  will  not  slip  about,  or  the 
cold  tub  be  disagreeable.  Cold  water  or  ice  water  is  added  at 
one  end  of  the  tub,  away  from  the  child,  and  the  water  thor- 
oughly mixed.     The  child  is  gently  rubbed,  legs  and  arms,  back 


Fig.     24. Collapsible     lurjner     rialH     tub. 

and  chest,  during  the  entire  time  it  is  in  the  water.  If  the 
teeth  begin  to  chatter  and  the  child  to  shiver,  the  bath  should 
not  be  prolonged.  No  hard  and  fast  rule  can  be  given  as  to 
the  duration  of  the  bath,  as  children  react  so  differently.  An 
average  duration  of  ten  minutes  is  the  proper  length  of  a  bath 
for  its  antipyretic  eifect. 

Should  a  child  object  to  the  bath  from  fright,  it  can  be  low- 
ered into  the  water  in  a  sheet  stretched  across  the  tub,  the  water 
gradually  covering  the  body. 

The  rectal  temperature  should  be  taken  just  before  the  bath 
and  30  minutes  afterward.  If  the  child  still  feels  hot  when 
it  is  removed  from  the  water  and  is  dried,  increased  radiation 
ea,n  be  accomplished  by  rubbing  with  a  weak  solution  of  alcohol, 
1  tablespoonful  to  6  ounces  of  water,  allowing  this  to  evaporate, 
the  sponging  being  continued  for  five  or  ten  minutes. 

A  preliminary  bath  before  the  physician  arrives  in  the  pres- 
ence of  temperature  above   103°   F.  is  always  indicated,   and 


THERAPEUTICS   OP    INFANCY   AND   CHILDHOOD.  79 

mothers  should  be  told  to  do  this  without  further  instructions. 

In  older  children  the  regular  bath  should  be  a  delight  instead 
of  a  bugbear.  In  those  who  are  susceptible  to  "colds,"  a  cool 
bath,  or  the  cool  sponge,  of  the  chest  and  back  following  a  warm 
bath  each  morning,  this  followed  by  a  brisk  rub,  is  of  the 
greatest  benefit.  With  some  children  the  spinal  douche  of  cold 
water  can  be  employed,  but  not  very  frequently.  Some  chil- 
dren prefer  a  cool  bath,  always.  I  have  two  boys  under  my 
observation,  aged  4  years  and  18  months,  who  have  a  daily  bath 
in  water  between  55°  F.  and  60°  F.,  and  object  to  a  tempera- 
ture even  as  high  as  70°  F. 

In  hot  weather,  a  second  bath  at  night  before  retiring  gives 
great  comfort  and  insures  a  good  night's  rest. 

Bran  Bath. — Two  teacupfuls  of  bran,  in  a  cheese-cloth  bag, 
to  enough  water  in  the  tub  to  cover  the  child's  legs  when 
sitting  in  the  water,  is  of  great  service  in  itching,  irritated,  skin, 
due  to  urticaria  and  prickly  heat.  The  water  is  splashed  on 
the  body  and  the  skin  is  not  rubbed.  The  temperature  of  the 
water  should  be  below  80°  F.  On  removal  from  the  tub  the 
skin  is  quickly  dried  with  soft  towels,  without  friction,  and 
the  surface  freely  powdered  with  talcum. 

Soda  Bath. — In  urticaria,  especially,  a  general  soda  bath  gives 
much  comfort,  or  a  basin  bath  may  be  used,  the  solution  being 
' '  sopped ' '  on  with  soft  gauze  or  washcloth.  If  a  general  bath  is 
given  use  a  half  teaeupful  of  the  bicarbonate  of  soda  to  the 
quantity  of  water  used  for  the  bran  bath,  or  a  tablespoonful  of 
the  soda  to  a  pint  of  water  for  the  basin  bath.  This  is  allowed 
to  drj'  on  the  skin  naturally. 

Mustard  Bath. — For  pulmonary  affections  the  mustard  bath 
is  of  the  greatest  service.  It  can  be  used  with  benefit  also  with 
children  in  convulsions,  or  very  nervous  and  irritable  ones.  Two 
heaping  tablespoonfuls  of  Coleman's  powdered  mustard  are  dis- 
solved in  five  gallons  of  water,  through  a  cloth  or  gauze,  in 
order  to  prevent  its  floating  on  the  surface,  and  sticking  to  the 
sides  of  the  tub.  Care  should  be  exercised  to  prevent  the  child 
rubbing  its  eyes  with  its  hands,  wet  with  the  mustard  water. 
The  mustard  bath  is  given  at  a  temperature  of  from  95°  F.  to 
100°  F.,  and  can  be  cooled  to  85°  F.,  just  before  child  is  re- 


80  THE   DISEASES   OP    CHILDREN. 

moved.  The  child  is  rubbed  vigorously  between  blankets  and 
put  in  bed  at  once  after  being  dried. 

Brine  Bath. — In  feeble  and  poorly-nourished  children  the  salt 
or  brine  bath  can  be  used  with  benefit,  as  it  acts  as  a  tonic  and,  as 
a  rule,  an  excellent  reaction  is  obtained.  Ordinary  salt,  or  if  it 
can  be  obtained,  sea-salt,  can  be  used,  one  or  two  tablespoonfuls 
to  the  gallon  of  water.  A  basin  bath  with  soap  and  water  can 
first  be  given,  and  the  child  then  put  in  the  salt  water,  the  skin 
being  rubbed  constantly  for  the  five  or  ten  minutes  it  is  kept  in 
the  water.  The  reaction  from  this  bath  is  usually  greater  than 
from  any  other  form. 

Nauheim  Baths. — The  artificial  Nauheim-Schott  treatment  ^ 
consists  in  the  use  of  brine  baths,  with  or  without  free  carbonic 
dioxid.  Their  object  is  to  enable  a  dilated  heart,  that  is  unable 
to  expel  its  contents,  to  empty  itself  completely. 

Briefly,  the  effects  of  the  baths  are  obtained  by  the  tempera- 
ture, duration  and  amount  of  salts  and  gas  contained  in  them. 

The  average  temperature  to  begin  with,  is  92.7°  F.,  the  re- 
duction not  more  than  2.2°  F.,  the  duration  usually  not  longer 
than  10  minutes.  The  minimum  temperature  of  any  bath  is 
81.5°  F.,  the  maximum  duration  of  20  minutes. 

Commercial  bicarbonate  of  sodium  and  crude  hydrochloric 
acid  (42  per  cent)  are  added  in  equal  quantities  by  w^eight  to 
the  bath  water.  In  the  beginning  one-fifth  of  a  pound  of  each 
is  added  to  62  gallons  of  water,  this  quantity  gradually  in- 
creased to  three  pounds  of  each.  The  bicarbonate  of  soda  is 
first  dissolved  and  poured  into  the  bath  water  and  the  acid 
added  w^hen  everything  else  is  ready.  It  is  added  by  pouring  it 
along  the  bottom  of  the  tub  under  the  water.  The  layer  of  car- 
bon dioxid  formed  on  top  is  removed  by  fanning,  the  window 
being  open. 

Wet  Cool  Pack. — As  an  antipyretic  measure  this  is  probably 
the  best,  and  one  which  is  infrequently  used  by  the  profession 
as  a  rule.  It  can  be  used  with  a  child  at  any  age,  and  may  be 
continued  for  long  periods  at  a  time,  10,  12,  or  as  in  a  case 
reported  by  Kerley,  for  72  hours.  The  bed  is  protected  by  a 
rubber  sheet,  which  is  covered  with  a  draw  sheet.     The  child 

1  Nothnngle's   Encyclopedia — Diseases   of   the    Heart. 


THEFLVPEUTICS   OF   INFANCY   AND    CHILDHOOD.  81 

is  then  stripped,  its  legs  being  covered  by  a  blanket.  A  large 
bath  towel  is  used  in  preference  to  a  sheet.  This  envelopes  the 
child's  chest,  and  is  pinned  loosely  enough  to  go  over  the  shoul- 
ders, like  a  baby's  pin  blanket,  leaving  the  arms  free  and  ex- 
tending down  as  far  as  the  middle  of  the  thighs.  With  bath 
thermometer  in  the  basin  of  water  at  the  bedside,  the  tempera- 
ture of  the  water  is  carefully  watched.  The  rectal  temperature 
of  the  child  is  taken  at  half-hour  intervals  in  order  to  learn  the 
rapidity  of  the  fall.     The  pack  is  first  put  on  dry. 

The  towel  is  Avet  thoroughly  with  water  at  90°  F.  or  95°  F.,  in 
order  not  to  shock  the  child,  the  water  being  put  on  the  towel 
from  a  piece  of  gauze  which  is  squeezed  on  it,  the  child  turned 
in  order  to  have  the  back  wet.  In  five  or  ten  minutes  the  water 
is  cooled  5°  F.,  and  the  towel  again  wet  in  the  same  way,  A 
child  with  a  temperature  of  105°  F.  quickly  dries  the  towel.  It 
is  the  aim  to  keep  it  wet  constantly.  Each  time  the  towel  is  wet 
the  water  is  cooled  until  it  reaches  70°  F.  Heat  to  the  feet  and 
cold  to  the  head  is  a  great  assistance.  An  ice  bag  may  be  laid 
against  the  head  or  cold  cloths  applied  to  the  forehead  and  vertex. 
The  pack  is  removed  when  the  temperature  is  reduced  to  102°  F. 

This  treatment  is  indicated  in  all  forms  of  pyrexia,  from 
whatever  cause.  Pneumonia,  the  exanthemata,  typhoid  fever, 
etc.  The  presence  of  a  rash  is  no  contraindication,  though  some 
difficulty  may  be  experienced  in  some  families  to  convince  anx- 
ious mothers  and  friends  that  it  will  not  ' '  drive  in  the  rash. ' ' 

Mustard  Plaster. — If  properly  applied,  a  mustard  plaster  is 
of  the  greatest  benefit  in  certain  conditions  of  the  respiratory 
tract,  and  where  counter  irritation  for  any  reason  is  desired. 
The  plaster  made  at  home  is  more  effective  and  less  disagreeable 
than  the  mustard  leaves  on  the  market.  If  the  skin  is  delicate 
and  irritable,  1  part  of  the  mustard  to  8  or  10  parts  of  flour 
will  be  found  very  serviceable.  The  mustard  flour  and  the  wheat 
flour  are  made  into  a  thick  paste  with  cold  water  and  spread 
between  two  thin  pieces  of  cloth,  warmed  before  the  fire  and 
placed  upon  the  skin.  The  plaster  is  allowed  to  remain  on  the 
skin  until  it  is  reddened,  which  can  be  ascertained  by  lifting  up 
the  corner  of  the  plaster.  After  removal  the  skin  is  greased 
with  vaseline,  and  when  the  skin  has  resumed  the  normal  hue 


82  THE   DISEASES   OF    CHILDREN. 

the  plaster  can  be  renewed,  a  fresh  one  being  made  each  time. 
Irrigation  of  the  Nose. — The  child  is  placed  on  the  nurse's 
lap  or  on  the  bed,  lying  upon  its  side,  its  head  slightly  lower 
than  its  body.  The  child  can  be  held  upright,  sitting  on  the 
nurse's  lap,  its  head  bent  slightly  forward  over  a  basin.  AVith 
either  a  fountain  syringe  or  glass  syringe,  with  a  rubber  tip, 
the  solution,  warmed  to  90°  F.,  is  put  into  the  upper  nostril 


V — \%       -IMM0.CO.         dii^^** 


Fig.  25. — Glass  syringe.      Soft  rubber  tip. 

and  allowed  to  run  out  of  the  lower  nares.  The  child  may  have 
to  be  wrapped  in  a  sheet  to  confine  its  arms  and  legs,  if  it  resists 
the  operation  very  much. 

Stomach  Washing.^ — Epstein  of  Prague,  in  1880,  recom- 
mended washing  th^  stomach  in  certain  diseases  of  the  gastro- 
intestinal tract.  Dr.  A.  Seibert  of  New  York,  in  1888,  advo- 
cated its  use,  and  since  then  lavage  has  been  extensively  used. 

The  apparatus  used  is  a  No.  13,  American  scale,  soft  rubber 
catheter,  not  too  flexible,  about  12  inches  in  length.  This  is 
attached  to  a  piece  of  rubber  tubing  2  feet  long,  with  a  short 
piece  of  glass  tubing  between.  A  glass  or  hard-rubber  funnel 
of  2  or  3  ounces  capacity  is  attached  to  the  free  end  of  the 
rubber  tubing. 

Plain  lukewarm  water  previously  boiled  is  the  only  fluid 
which  should  be  used,  and  as  a  rule  1  pint  is  all  that  is  necessary. 

The  child  is  seated  upright  in  the  nurse's  lap,  head  against 
her  right  shoulder.  A  rubber  apron  is  pinned  around  the  child's 
neck,  its  lower  end,  long  enough  to  reach  the  floor,  in  a  basin 
or  bucket,  in  front  of  the  nurse's  feet.  The  child's  hands  are 
held  by  one  of  the  nurse's  hands,  its  legs  by  the  other.  The 
child's  tongue  is  depressed  by  the  left  forefinger,  and  taking 
advantage  of  the  gagging  the  tube  is  rapidly  pushed  down  the 
esophagus  to  the  stomach.  The  tube  is  wet  before  being  intro- 
duced and  no  lubrication  is  needed. 

Some  gas  may  be  in  the  stomach  and  fill  the  tube,  which  will 
obstruct  the  inflow  of  the  first  water  poured  in  the  funnel,  or 

'  "Stomach  Washing  in   Infants,"   Tuley,   Medical  News,   .July   1,    1893. 


THERAPEUTICS   OF   INFANCY   AND    CHILDHOOD. 


83 


which  is  less  usual,  a  curd  or  bit  of  mucus  may  clog  the  eye 
of  the  catheter  for  a  few  moments.  Filling  the  funnel  and 
elevating  it  to  the  fullest  extent  usually  causes  the  water  to 
flow  in.  Through  the  glass  tubing  the  flow  of  the  water  can 
be  seen. 

Over-distending  the  stomach  with  water  causes  the  child  to 


\pparatus   for    stomach   washing. 


vomit  alongside  the  tube,  and  frequently  thick  leatherj^  curds 
are  ejected  which  could  not  have  readily  been  disintegrated. 

The  water  is  siphoned  out  as  soon  as  a  proper  amount  has 
been  allowed  to  run  in  and  the  process  repeated  until  the  wash 
water  returns  clear. 

In  removing  the  tube  it  should  be  grasped  firmly  in  order  to 
prevent  a  few  drops  falling  into  the  larynx  as  the  tip  of  the 
catheter  passes  over  the  epiglottis. 

After  the  washing,  the  stomach  should  be  kept  entirely  at 
rest,  and  only  the  easiest  digested  food  administered.  Epstein 
suggested  the  administration  of  egg  albumen  water  for  24  hours 
after  a  stomach  washing. 


84 


THE   DISEASES   OF    CHILDREN. 


Irrigation  of  the  Colon. — This  is  a  measure  frequently  abused 
and  improperly  applied,  yet  one  which  is  of  great  benefit  when 
properly  used.  It  has  been  suggested  as  an  antipyretic  measure, 
but  this  should  be  done  with  great  caution.  The  indications 
for  colon  irrigation  are  referred  to  elsewhere. 

A  No.  14,  American  scale,  soft  rubber,  velvet-eye  catheter, 
or  a  No.  17,  American  scale,  rectal  tube  with  opening  in  the 


Fig.    27.— Colon    irrigation.      Nurse's   lap    protected    by    rubber    sheet. 

end,  is  attached  to  the  small  tip  of  a  2  quart  fountain  syringe. 
The  solution  and  its  temperature  should  be  determined  by  the 
indications  to  be  met.  The  syringe  is  held  not  more  than  3 
feet  above  the  patient,  and  the  first  of  the  water  in  the  tube 
allowed  to  escape  so  it  will  run  in  an  even  temperature. 

The  child  is  held  either  on  the  nurse's  lap,  which  is  protected 
by  a  rubber  sheet,  or  on  a  bed,  close  to  the  edge,  on  its  back 
or  left  side  with  hips  elevated,  and  clothes  drawn  well  up  under 
its  shoulders.     A  napkin  can  be  pinned  loosely  around  its  waist 


THERAPEUTICS   OP   INFANCY    AND    CHIIjDHOOD.  85 

and  allowed  to  hang  loose  over  the  rubber  sheet.  A  receptacle 
of  some  kind  is  placed  under  the  rubber  sheet  to  catch  the 
return  water. 

The  tube  or  catheter  is  anointed  thoroujjhly  with  vaseline,  and 
also  the  anus,  as  this  will  make  it  much  easier  to  introduce  the 
tube.  After  the  tube  has  been  inserted  1  or  2  inches  the  com- 
pression is  removed  from  the  tube,  and  as  the  water  flows  in 
it  dilates  the  colon  ahead  of  the  tube,  making  its  insertion  easy 
as  a  rule.  If  straining  occurs,  the  tube  is  compressed  for  a 
moment  until  the  spasmodic  condition  is  relieved.  If  a  too 
flexible  tube  is  used,  as  the  tip  meets  a  fold  of  bowel,  it  is  apt 
to  be  bent  on  itself  and  forced  out  at  the  anus  during  straining. 

The  continuaus  irrigation  already  referred  to  is  a  measure 
of  the  greatest  benefit  in  conditions  such  as  sepsis,  and  failure 
of  elimination  by  the  kidney.  The  hips  are  slightly  elevated 
and  a  medium-size  catheter  is  introduced  half  way  into 
the  bowel.  The  bag  is  elevated  not  more  than  12  inches  above  the 
hips,  and  enough  compression  used  on  the  tube  to  cause  the 
w^ater  to  escape  in  drops,  at  a  rate  so  that  an  average  of  a  pint 
will  escape  an  hour.  The  temperature  of  the  w-ater  is  kept  at 
100°  F.,  by  the  addition  of  hot  water  from  time  to  time  as  it 
cools. 

Collection  of  Urine  for  Examination. — Unfortunately  the 
chemical  examination  of  the  urine  of  children  is  very  often 
neglected,  or  even  entirely  omitted  by  the  average  practitioner, 
and  probably  no  other  method  of  diagnosis  is  of  greater  impor- 
tance to  the  clinician.  In  very  young  babies  it  is  often  a  very 
difficult  thing  to  obtain  a  specimen,  especially  girl  babies,  and 
a  most  useful  device  has  been  suggested  by  Dr.  Chapin,^  which 
he  describes  as  follows : 

It  consists  of  a  circular  opening  ending  in  a  funnel  that  fits  in  a  collect- 
ing vessel.  Two  sizes  have  been  found  necessary,  small  and  large,  desig- 
nated respectively  as  Xo.  1  and  No.  2,  for  infants  under  and  over  one  year. 
The  urinal  is  fixed  in  place  by  putting  the  large  opening  around  the  vulva 
in  the  female,  and  over  the  parts  in  the  male,  with  the  funnel  pointed 
downward.  Tapes  are  put  through  the  openings  in  the  arms  and  fixed  by 
tying  around  the  abdomen  and  both  groins.  To  fix  more  firmly  in  place, 
strips  of  adhesive  plaster  may  be  pasted  over  the  arms.     The  end  of  the 


^American  Pediatric  Society.      (Archives  of  Pediatrics,  May,  1906). 


86  THE  DISEASES  OP   CHILDREN. 

funnel  is  placed  in  a  collecting  bottle  which  is  kept  in  position  by  the 
diaper.  If  the  baby  is  very  restless,  a  cork  may  be  put  in  the  end  of 
the  funnel  and  the  bottle  dispensed  with,  as  enough  will  often  be  thus 
collected  for  examination. 

If  the  child  is  too  ill  to  be  held  over  a  vessel  at  intervals,  if 
a  rubber  napkin  is  put  on  with  a  small  pledget  of  cotton  at 
the  nates,  some  urine  will  soon  be  caught,  enough  for  a  chem- 
ical and  microscopical  test.  It  should  be  borne  in  mind  that 
any  powder  used  about  the  vulva  may  contaminate  the  urine. 

As  an  example  may  be  mentioned  the  case  of  pyelitis  referred 
to  elsewhere.  The  urine  from  this  patient  was  submitted  to  an 
expert  clinical  pathologist  who  found  pus  and  albumen  in  the 
urine  and  also  an  object  under  the  microscope  resembling  the 
egg  of  an  intestinal  parasite.  It  was  finally  remembered  that 
lycopodium  was  used  with  talcum  powder  with  this  eliild,  and 
these  objects  were  the  seed  pods  of  the  lycopodium. 

Inunction. — The  skin  can  be  used  for  introducing  medicines 
into  the  system,  though  it  is  a  very  uncertain  method.  In 
athreptic  and  marasmic  children  some  absorption  of  fat  can  be 
obtained  by  inunction,  and  by  enveloping  the  child  in  cotton 
soaked  with  oil,  mercury  can  be  introduced  through  the  skin 
by  rubbing  the  ointment  into  the  flexures,  using  these  alternately. 


CHAPTER  VII. 

INFANT  FEEDING. 

Infant  Feeding. — All  forms  of  food  contain  essentially  the 
same  ingredients  viz.,  proteids,  fats,  carbohydrates,  mineral  mat- 
ter and  water.  From  conception  until  about  one  year  after 
birth,  the  supply  of  nourishment  is  obtained  from  the  mother. 
By  this  time  the  infant's  digestive  tract  is  developed  sufficiently 
for  it  to  care  for  soft  food  and  exist  independently  of  the  mother. 

Breast  Feeding. — ^No  substitute  has  ever  been  found  for  nor- 
mal mother's  milk  for  the  nourishment  of  the  infant.  Mother's 
milk  contains  the  food  elements,  fat,  sugar,  proteid,  mineral  water 
and  salts,  in  the  proportions  best  suited  for  its  digestive  capacity 
and  nutrition.  The  infant  should  be  put  to  the  breast  as  soon  as 
the  mother  has  had  a  r&st  from  her  labor,  as  the  colostrum,  pres- 
ent in  the  breast  before  labor,  is  essential  for  its  purgative  effect 
on  the  child.  During  the  first  24  hours  the  child  should  be 
nursed  every  six  hours ;  during  the  second  24  hours,  every  four 
hours;  during  the  third  24  hours,  every  three  hours;  during 
the  fourth  24  hours,  every  two  hours.  The  milk  usually  comes 
the  evening  of  the  second  or  the  morning  of  the  third  day,  after 
which  time  the  nursing  should  be  every  two  hours.  If  nursed 
every  two  hours  during  the  first  three  days  the  tugging  and 
pulling  on  a  flabby,  empty  breast  results  in  an  erosion  or  fissured 
nipple. 

A  cracked,  fissured  or  eroded  nipple  is  a  most  painful  and 
distressing  condition,  as  well  as  a  dangerous  one  from  the  pos- 
sibility of  an  infection  of  the  breast  occurring  through  this  open 
wound.  A  fissured  or  eroded  nipple  should  not  be  nursed  from 
directly,  but  protected  by  a  nipple  shield.  The  glass  shield  with 
rubber  nipple  and  guard  is  the  most  serviceable,  and  if  filled  with 
warm  water  when  applied  to  the  breast  will  encourage  the  child 
to  pull  when  the  nipple  is  placed  in  its  mouth.  Immediately 
after  each  nursing  the  nipple  should  be  painted  with  a  solution 

87 


88 


THE   DISEASES   OP    CHILDREN. 


of  nitrate  of  silver,  20  grains  to  the  ounce  of  water,  care  being 
taken  to  limit  the  application  directly  to  the  affected  part.  This 
forms  a  pellicle  from  the  coagulated  albumen  of  the  serum,  and 
allows  granulation  to  occur  beneath  it.  The  nipple  is  then  cov- 
ered with  a  piece  of  sterile  gauze  or  soft  linen. 

After  the  milk  comes,  the  nursing  should  be  by  schedule, 
every  two  hours  during  the  day  and  every  three  hours  at  night : 
From  6  a.  m  to  10  p.  m.  every  two  hours,  and  one  or  two 
nursings  at  night.  Under  no  conditions  should  a  baby  be 
allowed  to  sleep  with  its  mother;  the  danger  of  over-laying  is 
great,  as  is  the  danger  of  the  child  nursing  most  of  the  night. 
This  always  results  seriously  to  the  child's  digestion. 

Schedule  for  nursing  a  breast-fed  baby : 


AGE. 

INTERVAL   DAY. 

NUMBER  NIGHT 
NURSINGS. 

NUMBER  OF 
NURSINGS  24  HR. 

First  three  days 

Until  end  of  first  month . . 
Second  and  third  months. 
Fourth  and  fifth  months.  . 
Sixth  to  twelfth  months . . 

4    to    6 

2 

2i 

3 

3 

1 

2 

1 
1 
0 

4    to    6 
10 

8 
7 
6 

The  child  should  nurse  from  one  breast  at  each  nursing, 
alternately,  and  should  be  satisfied  in  from  10  to  15  minutes. 
If  it  must  be  nursed  from  both  breasts  each  time,  and  is  unsat- 
isfied when  the  nursing  is  finished,  the  quantity  is  inadequate 
for  its  needs.  By  regularity  being  established  early  both  the 
baby  is  trained  to  good  habits,  and  the  breasts  to  secrete  at 
regular  intervals. 

The  nipples  should  be  washed  before  and  after  nursing  with  a 
solution  of  boracic  acid,  and  the  child's  mouth  thoroughly 
cleansed  before  and  after  the  nursing  with  the  same  solution. 

It  should  be  a  rule  to  give  water  to  a  nursing  baby  between 
feedings.  Before  the  milk  comes,  in  order  to  prevent  a  too  rapid 
loss  of  weight,  there  should  be  given  at  regular  intervals  a  2  per 
cent  solution  of  sugar  of  milk,  or  even  plain  sterile  water. 

There  are  but  few  contraindications  to  maternal  nursing.  A 
severely  inverted  nipple  makes  it  impossible  for  the  child  to 
nurse.     Nursing   should  not   be   allowed   in   mothers   suffering 


INFANT   FEEDING.  89 

from  tuberculosis  in  any  form;  malignant  disease;  diphtheria; 
rheumatism  or  chorea ;  acute  contagious  diseases  and  pneu- 
monia; erysipelas;  albuminuria;  typhoid  fever,  as  the  typhoid 
bacillus  is  excreted  in  the  breast  milk;  the  acute  exanthemata; 
pregnancy  occurring  during  lactation ;  epilepsy  or  nephritis,  or 
if  the  mother  has  suffered  from  puerperal  hemorrhage,  nephritis, 
eclampsia  or  infection. 

Nursing  Mother. — A  nursing  mother  should  lead  a  perfectly 
normal,  healthy  life.  Her  diet  should  be  generous  and  varied. 
There  are  practically  no  articles  of  diet  which,  if  they  agree 
with  the  mother,  will  cause  the  milk  to  disagree  with  the  child. 

During  the  first  three  days  of  the  puerperium  the  diet  should 
be  light  and  easily  digested.  The  following  sample  diet  list 
for  the  first  few  days  will  generally  yield  good  results : 

First  day  (after  labor)  : 

Breakfast — Cup  of  tea,  or  cocoa;  piece  of  dry  or  buttered  toast. 

Lunch — Beef,  chicken  or  mutton  broth;  toast  or  wafer. 

Supper — Glass  of  milk,  or  cup  of  tea. 
Second  day: 

Breakfast — Cereal  and  cream  with  cocoa  or  tea. 

Lunch — Soft-boiled  egg,  rice  and  cream. 

Supper — ^Milk  toast,  tea  or  milk. 
Third  day: 

Breakfast — Soft  boiled  egg,  cereal,  coflFee  or  milk. 

Lunch — Baked  potato,  gelatin  jelly  and  cream,  and  milk. 

Supper — Baked  apple  and  cream  or  milk  toast. 
Fourth  day   (after  bowels  have  moved)  : 

Breakfast — Cereal,  poached  egg  on  toast,  breakfast  bacon,  and  cocoa 
or  milk. 

Lunch — Squab  or  bird,  potato  chips  or  baked  potato;  cocoa. 

Supper — Mush  and  milk. 
Fifth  day: 

Breakfast — Cereal,   broiled    steak,   hashed   brown   or   baked    potato; 
milk. 

Lunch — Chicken,  broiled  or  baked;   mashed  potatoes,  sweet  potatoes, 
asparagus  tip  salad. 

Supper — Milk  toast. 
Sixth  day: 

Breakfast — Lamb  chop,  soft  boiled  or  poached  egg,  toast,  cocoa  and 
milk. 

Lunch — Junket,  cocoa,   spinach,   potato. 


90  THE   DISEASES  OF    CHILDREN. 

Supper — Baked  apple  or  prunes,  toast  and  milk. 
Bran  muffins  made  of  bran  and  flour,  equal  parts,  are  especially  useful 
during  this  period  as  a  prevention  of  constipation. 

Strict  attention  should  be  paid  to  her  bowels,  and  at  least  one 
evacuation  had  daily.  It  must  be  remembered,  however,  that 
there  are  a  few  purgatives  which  are  excreted  through  the  milk. 
I  have  frequently  noticed  a  purgative  effect  on  the  child  when 
the  mother  had  been  taking  cascara  in  some  form.  She  must 
have  at  least  a  half  hour's  exercise  in  the  open  air  daily  and 
longer,  if  possible. 

If  the  child  is  satisfied  after  nursing  and  during  the  interval; 
is  gaining  in  weight  regularly;  is  happy  and  bright;  it  may  be 
asserted  the  milk  is  both  up  to  the  standard  in  quantity  and 
quality.  If  the  child  is  satisfied  but  a  short  while  after  nursing, 
soon  shows  signs  of  hunger  and  the  supply  apparently  adequate, 
then  it  is  deficient  in  quality.  If  a  milk  is  normal  in  amount, 
but  deficient  in  certain  ingredients,  it  can  often  be  corrected 
and  made  to  agree  with  the  child. 

The  Method  of  Nursing. — Primipara  should  be  instructed  in 
the  proper  method  of  putting  the  child  to  the  breast  and  holding 
it  while  nursing.  During  the  puerperium,  the  mother  lying 
partly  on  her  side,  the  baby  is  put  to  the  breast  so  it  can  readily 
grasp  the  nipple,  which  has  been  previously  prepared,  and  one 
finger  depresses  the  gland  so  that  it  will  not  press  upon  the 
nose  and  interfere  with  its  breathing.  The  baby  can  either  be 
supported  upon  the  arm  or  lie  flat  upon  the  bed,  the  mother's 
arm  being  raised. 

Holding  the  breast  so  as  not  to  obstruct  the  child's  breathing 
is  most  important.  I  know  of  one  normal  baby  when  12  hours 
old  entirely  asphyxiated  from  being  allowed  to  bury  its  nose 
in  the  breast. 

"Wheri  able  to  sit  up  to  nurse,  the  mother  occupies  a  low 
chair  wdth  a  footstool,  upon  which  rests  the  foot  of  the  side 
from  which  the  baby  nurses.  The  baby  is  held  upon  the  arm, 
and  the  mother  leaning  forward  slightly  places  the  nipple 
squarely,  not  obliquely,  in  mouth. 

Breast  Milk. — Breast  milk  is  more  bluish-white  than  yellow, 
and  has  been  shown  by  Kerley  and  others  to  be  faintly  acid 


INFANT   FEEDING. 


91 


when  tested  with  1  per  cent  alcoholic  solution  of  phenolphthalein. 
By  others  it  is  claimed  breast  milk  is  amphoteric,  that  is,  it  is 
alkaline  to  red  litmus  and  acid  to  blue  litmus. 


11'* 

Fig.    28. — Holt's    milk    set. 

The  following  table  is  given  by  Holt,  showing  the  composi- 
tion of  breast  milk : 

Average 
Per  cent. 
4.00 


Fat  . .  .  . 
Sugar  .  . 
Proteids 
Salts  .  . 
Water    . 


Common  healthy  variations 

Per  cent. 

3.00  to       5.00 


7.00 

6.00  to 

7.00 

1.50 

1.00  to 

2.25 

0.20 

0.18  to 

0.25 

87.30 

89.82  to 

85.50 

100.00 


100.00 


100.00 


Milk  must  be  thought  of  as  a  homogeneous  mixture,  its  chief 
ingredients  being  fat,  sugar  and  proteids,  and  the  percentages 
of  these  must  be  definite  and  stable  if  the  milk  will  agree  with 
the  child.  The  usually  accepted  analysis  of  mother's  milk 
shows,  fat  3.5  per  cent,  sugar  6  per  cent,  proteids  1.5  per  cent. 

An  examination  of  breast  milk  by  means  of  the  Holt  clinical 
milk  set  will  show  a  more  or  less  wide  variation  in  the  proteid 
and  fat  content  in  the  same  individual  at  ditferent  times  of  the 
day.     There  is  always  wider  variation  in  these  constituents  than 


92  THE   DISEASES   OF   CHILDREN. 

in  the  sugar,  which  is  more  or  less  constant.  As  already  stated, 
the  quantity  of  the  milk  may  be  sufficient  for  the  child's  needs, 
but  the  quality  much  below.  The  quantity  obtained  at  a  feed- 
ing can  be  determined  by  weighing  the  child  before  and  after 
nursing,  as  was  done  in  a  number  of  cases  by  the  writer,  which 
were  reported  in  the  Archives  of  Pediatrics  (May,  1893). 

Each  baby  was  weighed  M'ith  all  of  its  clothes  on  before  and 
directly  after  each  nursing,  with  the  nurse's  and  mother's  assist- 
ance, being  sure  that  the  baby  was  kept  awake  during  the  entire 
20  minutes  it  was  allowed  to  nurse.  The  weighing  was  care- 
fully done  upon  one  of  Fairbanks'  scales  which  registered  in 
half  ounces  with  no  change  being  made  in  clothing  between 
weighings.  Elimination  of  error  was  by  this  means  made  pos- 
sible which  might  occur  from  loss  in  weight  by  excrement  from 
the  child  or  from  a  difference  in  the  texture  of  the  napkins  ap- 
plied. Eight  babies  were  weighed,  64  weighings  being  recorded. 
The  babies  were  from  two  to  ten  days  of  age,  healthy,  and  all 
weighing  6  pounds  or  more  at  birth. 


Aver,  iceight  of 

Age 

-A' 

umber 

of 

ingested-milk 

Days 

^^ 

'eighings 

Ounces 

2 

2 

1.25 

3 

13 

1.3 

4 

3 

1.0 

5 

10 

1.5 

6 

6 

1.25 

7 

13 

2.27 

8 

6 

2.25 

9 

8 

2.5 

10 

3 

2.5 

Given  a  case  in  which  there  was  but  little  gain  after  a  week's 
nursing  or  in  which  there  is  continued  colic  or  curds  passed  in 
large  quantities,  the  breast  milk  should  be  examined.  This  may 
be  done  clinically  by  Holt's  Milk  Set,  or  chemically,  for  an  accu- 
rate estimate  of  the  fat,  proteid  and  sugar  content,  or  by  the 
use  of  the  pioscope.  The  Babcock  test  may  be  made  for  the 
estimate  of  the  fat  content,  which  when  taken  in  connection  with 
the  specific  gravity  will  give  a  fairly  accurate  idea  of  the  quality 
of  milk. 


INFANT    FEEDING. 


93 


The  child  should  be  put  to  the  breast  and  allowed  to  nurse 
for  three  minutes,  and  a  half  ounce  of  milk  either  pressed  or 
pumped  from  the  breast^  and  if  enough  cannot  be  obtained  from 
one  side  the  other  is  treated  in  the  same  way. 

Holt 's  directions  for  the  use  of  his  milk  set  are  as  follows : 

The  simplest  method  is  by  the  cream-gauge.  Although  its  results  are 
only  approximate,  they  are  in  most  cases  sufficiently  accurate  for  clinical 
purposes.  The  tube  is  filled  to  the  zero  mark  with  freshly  drawn  milk, 
which  stands  at  room-temperature  for  twenty-four  hours,  when  the  per- 
centage of  cream  is  read  off.  The  ratio  of  this  to  the  fat  is  approximately 
five  to  three;  thus  5  per  cent  cream  indicates  3  per  cent  fat,  etc. 

Sugar.  The  proportion  of  sugar  is  so  nearly  constant  that  it  may  be 
ignored  in  clinical  examination. 

Proteids.  We  have  no  simple  method  for  determining  clinically  the 
amount  of  proteids.  If  we  regard  the  sugar  and  salts  as  constant,  or  so 
nearly  so  as  not  to  affect  the  specific  gravity,  we  may  form  an  approximate 
idea  of  the  proteids  from  a  knowledge  of  the  specific  gravity  and  the  per- 
centage of  fat.  We  may  thus  determine  whether  they  are  greatly  in  excess 
or  very  low,  which,  after  all,  is  the  important  thing.  The  specific  gravity 
will  tlien  vary  directly  with  the  proportion  of  proteids,  and  inversely  with 
the  proportion  of  fat,  i.  e.,  high  proteids,  high  specific  gravity;  high  fat, 
low  specific  gravity.  Tlie  application  of  this  principle  will  be  seen  by 
reference  to  the  accompanying  table. 

woman's  milk. 


SPECIFIC    GRAVITY, 

CREAM, 

PROTEID 

70°  F. 

24  HRS. 

CALCULATED. 

Average     

1.031 

7  per  cent 

1.5  per  cent 

Normal    variations... 

1.028-1.029 

8  per  cent-12 

Normal    (rich 

per  cent 

milk) 

Normal    variations... 

1.0.32 

5   per  cent-6 

Normal    ( fair 

per   cent 

milk) 

Abnormal    variations. 

Low  (Inflow    1.028) 

Higli  (above  10 

Normal    ( or 

per  cent) 

slightly  be- 
low) 

Abnormal    variations. 

Low  (iK'low    1.028) 

Low     ( below    5 

Very           low 

per  cent) 

( very  poor 
milk) 

Abnormal    variations . 

High  (above  1.032) 

High 

Very  high 
( very  rich 
milk) 

Abnormal   variations! 

High  (above  1.032)' 

Low 

Normal  (or 
nearly  so) 

94  THE   DISEASES   OF   CHILDREN. 

Any  specimen  taken  for  examination  should  be  either  the  middle  portion 
of  the  milk,  i.e.,  after  nursing  two  or  three  minutes — or,  better,  the  entire 
quantity  from  one  breast,  since  the  composition  of  the  milk  will  diifer  very 
much  according  to  the  time  when  it  is  drawn.  The  first  milk  is  slightly 
richer  in  proteids  and  much  poorer  in  fat. 

'  The  **pioscope"  is  an  instrument  used  for  testing  breast  milk. 
It  is  composed  of  two  disks,  the  lower  one  of  hard  rubber,  the 
upper  one  of  glass.  The  latter  is  divided  into  sections  labeled 
and  colored  to  represent  milk  of  different  qualities,  normal,  very 
fat,  cream,  very  poor,  poor,  less  fat.  The  milk  immediately 
after  being  drawn  from  the  breast  is  placed  in  a  small  depression 
in  the  center  of  the  rubber  disc.  The  glass  is  then  placed  over  it 
and  as  the  milk  is  spread  out,  the  quality  of  the  milk  can  be 
read  by  comparing  with  the  sections  on  the  glass  disc. 

The  problems  to  be  met  in  the  supervision  of  "breast  feeding 
are :  1.  The  increase  of  a  too  small  supply.  2.  Changing  the 
character  of  the  milk,  (a)  decreasing  the  proteids,  (b)  increas- 
ing the  fat,  (c)  decreasing  the  fat.  3.  To  make  serviceable 
nipples  out  of  flat  and  depressed  ones.  4.  To  supply  an  arti- 
ficial or  adjuvant  food  in  case  of  a  good  but  too  small  supply 
from  the  breast.  5.  To  continue  nursing  should  there  be  a 
suppurating  mastitis,  and  retain  the  integrity  of  the  gland  after 
a  subsidence  of  the  inflammation. 

While,  as  a  general  rule,  it  may  be  stated  the  ideal  food  is  a 
healthy  breast  milk,  this  is  not  always  the  case,  for  not  infre- 
quently a  mother  has  an  abundant  supply  but  secretes  a  milk 
which  is  unsuited  to  the  needs  of  her  own  baby.  These  eases, 
however,  are  the  exception,  and  it  is  infrequent  that  we  find  an 
unsuitable  breast  milk  which  cannot  be  changed  by  suitable 
remedial  measures,  hence  I  cannot  refrain  from  saying  a  word 
against  the  unnatural  mother  who  refuses  to  nurse  her  infant 
from  purely  selfish  reasons,  that  she  may  have  more  time  for 
society  or  pleasure.  No  physician  should  be  a  party  to  this  or 
encourage  it  in  any  way,  unless  it  can  be  plainly  shown  by  most 
careful  examination  that  the  milk  is  unsuited  and  beyond  reme- 
dial measures.  The  very  fact  that  artificially  fed  infants  show 
so  much  greater  rate  of  mortality  than  the  breast-fed  infant,  is 
sufficient  reason  for  advocating  breast  feeding. 


INFANT   FEEDING.  95 

While  it  may  be  a  fact  in  the  larger  centers  of  population 
that  mothers  are  unfeeling  and  unnatural  enough  to  allow  social 
obligations  to  interfere  with  nursing  their  babies,  we  believe  that 
in  the  South  and  West  this  is  seldom  seen.  There  are  undoubt- 
edly cases  where  weaning  must  be  decided  upon,  in  which  the 
child  does  not  gain,  or  there  is  continual  disagreement  of  the 
milk  in  spite  of  efforts  to  change  the  constituents.  I  have  seen  a 
number  of  cases  in  which  the  necessity  for  weaning  has  arisen 
early  from  insurmountable  reasons.  These  have  been  enough 
to  impress  on  me  the  folly  of  voluntarily  surrendering  a  good 
breast  milk  supply  for  the  uncertainties  of  artificial  feeding. 

It  is  entirely  possible  to  combine  the  food  elements  present 
in  milk  of  the  lower  animals  in  the  exact  chemical  proportions  as 
in  mother's  milk,  but  there  is  lacking  that  fine  adjustment  of 
digestibility  found  in  the  milk  of  the  mother. 

The  following  analyses  are  given  of  colostrum: 

Winslow  Pfeiffer 

Fat    .     4.00  2.04 

Sugar 1.5  3.74 

Proteids   14.8  5.71 

Salts     1.00  0.25 

Water     78.7  88.23 


100.00  100.00 

Colostrum  is  more  yellow  in  color  than  milk,  does  not  coagu- 
late readily  except  on  boiling  and  contains,  in  addition  to  the 
small  regular  size  fat  globules,  the  large  granular  colostrum 
corpuscles.  These  may  persist  in  the  milk  until  after  the  second 
week,  but  usually  are  not  present  after  the  tenth  day.  They 
recur  during  lactation,  during  menstruation  and  under  the  stress 
of  great  mental  excitement,  fear,  anger,  sorrow,  sexual  excite- 
ment, etc.  When  present  abnormally,  similar  symptoms  appear 
to  those  which  occur  soon  after  birth,  diarrhea,  and  frequently 
vomiting.  Compared  with  milk,  colostrum  has  a  higher  per- 
centage of  proteids  and  less  sugar  and  fat. 

Besides  this  change  which  occurs,  the  milk  may  be  influenced 
by  any  temporary  illness  of  the  mother,  as  influenza  or  grippe ; 
or  any  serious  or  prolonged  illness,  as  typhoid  fever,  which 
would  interrupt  the  nursing  entirely. 


96  THE   DISEASES   OF    CHILDREN. 

Certain  drugs  are  said  to  be  excreted  in  breast  milk;  as 
opium,  belladonna,  caseara,  mercury,  iodides,  bromides  arid 
salicylates.  The  elimination  of  drugs  in  the  milk  is  not  suffi- 
ciently certain  or  exact  to  employ  this  method  of  medication 
in  infants,  nor  enough  to  remove  the  child  from  the  breast  for, 
if  any  of  these  drugs  were  indicated  in  the  mother. 

The  following  case  illustrates  colostrum  disagreement: 

A  mother  began  to  menstruate  four  weeks  after  her  delivery. 
Immediately  her  baby,  which  was  doing  well  previously,  began 
vomiting  and  purging.  The  second  month  the  menstruation 
recurred  with  similar  symptoms  in  the  baby.  I  was  called  to 
see  the  child  at  this  time  and  an  examination  of  the  breast 
milk  showed  it  to  be  heavily  loaded  with  colostrum  corpuscles. 
The  child  was  ill  for  several  days,  was  weaned,  and  for  one 
year  was  a  constant  care  and  anxiety,  because  of  the  difficulty 
of  finding  a  suitable  food  or  milk  modification  for  it. 

There  may  be  ample  supply  of  good  milk,  but  the  absence  of 
a  serviceable  nipple  may  prevent  the  child's  obtaining  it.  This 
may  be  often  seen,  and  it  should  be  a  routine  practice  to  make 
as  early  an  examination  of  the  breasts  and  nipples  of  a  preg- 
nant woman  as  possible,  especially  in  primipara,  in  order  to 
give  instructions  in  the  massage  of  flat  and  depressed  nipples. 
By  massage  and  training  a  very  serviceable  nipple  can  be  made 
from  an  unpromising  one  if  the  treatment  is  begun  early  enough. 
The  wearing  of  tight  corsets  or  clothing  should  be  advised  against 
during  pregnancy,  but  especially  in  the  presence  of  flat  or  de- 
pressed nipples.  A  careful  inquiry  should  also  be  made  of 
multipara  in  regard  to  their  lactation  history,  as  having  a  bear- 
ing on  the  possibility  of  nursing  the  new  baby. 

The  nipples  during  the  last  two  months  of  pregnancy,  should 
be  prepared  for  nursing  after  the  method  of  Mabbott.  Each 
evening  a  small  bit  of  lanolin  is  rubbed  into  the  nipple  and  sur- 
rounding areola,  and  as  part  of  the  toilet  in  the  morning,  with  a 
coarse  wash  cloth  and  soap  they  are  washed,  dried  and  dusted 
with  talcum. 

A  stationary  weight,  or  a  loss  after  the  second  week;  vomit- 
ing, not  simply  a  slight  regurgitation ;  colic ;  continuous  crying ; 
diarrhea,  with  green  movements,  containing  curds  and  mucus, 


INFANT   FEEDING.  97 

should  be  an  indication  for  a  close  investigation  of  the  breast 
milk,  the  frequency  and  time  of  nursing  and  the  daily  routine 
of  the  baby's  life. 

A  too  high  percentage  of  proteids  is  evidenced  by  colic,  cry- 
ing, with  a  doubling  up  of  the  legs,  tense  abdomen,  green  stools 
containing  mucus  and  curds.  This  very  often  occurs  during 
the  puerperium,  but  as  soon  as  the  mother  gets  up  and  is  able  to 
take  the  proper  exercise,  the  increased  proportion  of  proteids  is 
generally  decreased.  Should  this  relatively  high  percentage  of 
proteids  with  low  percentage  of  fat  persist,  and  the  plentiful 
supply  keep  up,  much  help  can  be  had  from  pumping  or  milking 
out  the  foremilk  from  the  breast,  the  child  being  allowed  to  nurse 
only  the  middlemilk  and  strippings.  Taking  the  child  from 
the  breast  before  it  has  finished  nursing  and  giving  it  a  small 
quantity  of  barley  water,  previously  dextrinized,  from  a  bottle, 
will  often  relieve  the  colic,  lessen  the  diarrhea  and  make  the 
curds  smaller. 

Too  much  fat,  which  I  have  met  but  a  few  times,  causes 
vomiting  and  diarrhea,  with  few  or  no  curds  in  the  movements. 
If  too  much  fat  is  present  there  may  be  found  in  the  stools 
small,  round  masses  which  resemble  casein  curds  very  much, 
but  are  smooth  and  soft  and  not  so  white  as  casein  curds. 

A  too  small  milk  supply  calls  for  active  treatment.  It  is 
evidenced  by  a  stationary  weight  or  a  loss  in  the  weight  of  the 
infant;  crying  within  a  few  minutes  after  leaving  the  breast 
and  sucking  vigorously  on  its  fists  after  nursing.  If  the  de- 
ficiency in  supply  is  the  only  fault,  it  may  frequently  be  in- 
creased by  such  galaetagogues  as  nutrolactis  or  somatose,  free 
drinking  of  milk,  cocoa  or  chocolate  and  the  cereal  gruels. 

These  gruels  may  be  made  of  oatmeal,  barley  or  cornmeal. 
After  thorough  cooking  for  several  hours,  they  are  ready  to 
serve,  enough  milk  being  added  so  they  can  be  drank  from  a 
cup  or  eaten  with  a  spoon.  No  article  of  diet  so  stimulates  the 
function  of  the  gland  as  cow's  milk,  and  in  connection  with  the 
cereals  excellent  results  are  seen. 

Alcoholic  beverages  are  to  be  avoided,  as  they  encourage  the 
secretion  of  a  milk  with  a  deficiency  in  its  life-giving  properties 
and  an  increase  in  the  watery  element. 


98  THE   DISEASES   OF    CHILDREN. 

If  these  measures  do  not  correct  the  difficulty,  the  child  should 
be  kept  on  a  modified  cow's  milk,  of  suitable  formula,  in  addi- 
tion to  the  nursing,  giving  at  first  1  or  2  drachms  to  an  infant 
of  four  weeks  immediately  after  a  breast  feeding,  gradually  in- 
creasing the  amount  as  indicated.  This  will  generally  suffice 
to  obtain  a  satisfactory  gain  in  its  weight. 

With  a  good  milk  supply,  regularity  of  nursing,  infrequent 
or  no  night  nursing,  a  child  will  generally  do  well ;  a  good  supply 
with  a  disregard  of  these  requisites  will  result,  perhaps,  in  seri- 
ous digestive  derangements.  Should  a  combined  breast  and  arti- 
ficial feeding  be  necessary,  the  one  or  two  night  feedings  should 
be  breast  milk  if  for  no  other  reason  than  the  convenience  to 
the  parents.  The  only  objection  to  this  is  the  possibility  of 
the  mother  falling  asleep  and  allowing  the  child  to  lie  with  the 
nipple  in  its  mouth  for  several  hours  at  a  time. 

To  increase  the  quantity  of  the  milk,  give  more  nutritious 
diet,  more  milk  and  cereal  gruels. 

To  increase  fat,  give  milk  and  meat. 

To  decrease  fat,  give  less  meat  and  milk  and  increase  the 
water. 

To  increase  the  proteids,  give  more  meat  and  eggs;  lessen 
exercise. 

To  decrease  proteids,  increase  exercise  to  point  of  fatigue  and 
decrease  meat. 

Wet  Nurse. — In  premature  infants  with  no  maternal  milk 
supply,  or  where  sudden  w^eaning  from  any  cause  becomes  im- 
perative, a  wet  nurse  should  be  obtained. 

The  selection  of  a  wet  nurse  is  beset  with  many  difficulties. 
The  following  should  be  taken  under  consideration:  the  age  of 
the  wet  nurse,  the  age  and  weight  of  her  infant,  the  nurse 's  gen- 
eral health,  development  and  general  surroundings.  A  careful 
physical  examination  should  be  made  of  both  the  nurse  and  her 
baby  and  tuberculosis  and  syphilis  positively  excluded.  If  there 
is  time  her  breast  milk  should  be  carefully  analyzed  before  she 
is  engaged.  The  diet  of  the  nurse  should  not  vary  greatly  from 
what  she  has  been  accustomed  to,  as  lack  of  exercise  may  change 
the  character  of  her  milk  entirely. 


INFANT   FEEDING.  99 

Weaning". — It  is  well  to  begin  weaning  an  infant  at  about  8 
months  of  age ;  with  at  first  one  feeding  a  day,  then  two,  gradu- 
ally displacing  the  nursings  by  an  additional  bottle  feeding,  un- 
til at  the  end  of  the  first  year  entire  weaning  has  been  accom- 
plished. 

The  weaning  may  be  accomplished  suddenly,  but  frequently 
not  without  considerable  gastric  and  intestinal  disturbance  being 
caused  in  the  child. 

Combined  Feeding. — If  it  is  apparent  that  a  child  is  not  gain- 
ing rapidly  wliile  nursed  exclusively,  by  giving  one  or  two  arti- 
ficial feedings  a  day,  of  modified  cow's  milk,  very  good  results 
can  frequently  be  obtained. 

As  when  entire  artificial  feeding  is  begun,  so  when  only  par- 
tially fed,  a  much  weaker  formula  should  be  given  than  nece^ 
sary  for  the  child's  needs  to  begin  with,  and  gradually  increase 
the  strength  of  the  formula  until  one  is  reached  upon  which  it 
will  be  contented,  and  will  gain  in  weight. 

It  is  frequently  a  very  good  plan  when  a  child  is  a  few  weeks 
old  to  give  it  one  bottle  a  day,  in  order  to  accustom  it  to  an  arti- 
ficial food,  and  also  to  enable  the  mother  to  have  a  few  extra 
hours  of  recreation,  occasionally,  if  the  demand  arises. 

Artificial  or  Substitute  Feeding. — A  mother  being  unable  to 
nurse  her  infant,  and  a  wet  nurse  is  nowhere  to  be  found,  the 
child  must  be  nourished  artificially.  Infants  can  not  be  fed 
by  rule ;  each  is  a  law  unto  itself ;  what  will  agree  with  one  will 
disagree  with  another.  Adapted  or  modified  cow's  milk  offers 
the  best  results,  but  the  first  principle  to  be  learned  is  that  one 
must  think  in  percentages,  not  in  standard  formulae  which  can 
be  given  to  this  or  that  baby  of  a  certain  age.  The  minimum 
food  requirements  must  be  combined  in  a  scientific  adaptation, 
and  the  proper  adjustment  made  later,  sufficient  to  cause  regular 
gains  in  weight.  With  careful  daily  weighing,  and  inquiry 
into  the  condition  of  the  digestion,  a  gaining  formula  will  soon 
be  decided  upon. 

One  Cow's  Milk. — It  has  long  since  become  an  accepted  fact 
that  the  milk  from  one  cow  should  not  be  used  for  infant  feed- 
ing.    Mixed  milk  from  a  herd  is  more  uniform  in  composition, 


100  THE   DISEASES   OF    CHILDREN. 

and  there  is  less  likelihood  of  changes  occurring  in  the  milk  as 
the  result  of  fright,  or  disease  being  harmful  because  of  its  dilu- 
tion with  the  herd's  milk. 

Cow's  Milk. — Because  of  the  universal  supply  of  cow's  milk, 
and  the  fact  that  it  contains  the  same  general  constituents  of 
and  can  be  modified  to  nearly  resemble  mother's  milk,  it  is  the 
best  substitute  for  normal  mother's  milk,  when  artificial  feeding 
is  necessary.  A  comparative  analysis  of  mother's  and  cow's 
milk  is  here  given: 

Mother's  Cow's 

Milk  Milk 

■      Fat    4.0  4.0 

Sugar 7.0  4.0 

Proteids    1.5  3.5  to  4.0 

No  food  product  is  so  capable  of  contamination  as  milk,  or  as 
little  average  intelligence  used  as  in  its  production  and  care. 
How  common  is  the  saying,  especially  in  cities,  when  the  diet 
of  a  sick  child  is  under  discussion:  "Take  it  to  the  country 
where  you  know  good  milk  can  be  obtained."  It  is  a  fact  that 
but  few  people  in  the  country,  unless  in  the  scientific  dairy  busi- 
ness, know  the  first  principles  of  the  production  and  handling  of 
milk. 

Certified  Milk. — Realizing  this  fact,  and  that  pure  milk,  espe- 
cially for  infants,  sick  children  and  invalids,  was  a  necessity. 
Dr.  Henry  L.  Coit  of  Newark,  N.  J.,  in  1894,  suggested  the  plan 
of  securing  a  dairyman  who  would  produce  milk  and  handle  it 
in  a  scientific  manner,  according  to  the  rules  of  a  financially 
disinterested  commission  of  physicians. 

This  was  done,  and  the  product  of  this  dairy  was  termed 
"Certified  Milk,"  the  term  being  registered  at  the  Patent  Office 
in  Washington  by  the  dairyman,  Mr.  Stephen  Francisco,  and 
Dr.  Coit.  They  have  very  generously  allowed  the  use  of  the  term 
by  similar  commissions,  and  a  number  of  the  larger  cities  have 
such  a  supply.  In  1907,  at  Atlantic  City,  was  formed  the  Ameri- 
can Association  of  Medical  Milk  Commissions,  with  Dr.  Coit  as 
its  first  president,  its  membership  composed  of  the  members  of 
milk  commissions  throughout  the  country,  and  dairy  scientists 
in  this  country  and  abroad.     This  association  has  done  much 


INFANT   FEEDING. 


101 


toward  systematizing  and  making  more  uniform  the  rules  and 
standards  and  working  methods  of  commissions  and  populariz- 


Fig.    29. — Wliere   cleanliness    is    ii    leligioii.      Ceitilied    Dairy    No.    -,    Louisville. 

ing  this  plan  of  obtaining  at  least  one  pure  supply  of  milk  in  the 
larger  centers  of  population. 

Kentucky  has  a  law  which  limits  the  use  of  the  term  ''Certified 
iMilk"  to  a  milk  commission  regularly  appointed  by  a  county 
medical  society.  This  effectually  prevents  the  use  of  the  term 
by  a  dairyman,  •  for  commercial  reasons,  without  producing  the 
milk  according  to  the  requirements  of  a  commission.     New  York 


102 


THE   DISEASES   OP    CHILDREN. 


and  New  Jersey  also  have  such  a  law.     The  Kentucky  law  is  as 
follows : 

An  act  for  preventing  the  niannfacturing  and  sale  of  adulterated  or  mis- 


Fig.   29a. — Immaculate  milking   conditions.      Certified   Dairy   No.   '2.^ 

branded   foods,  drugs,   medicines  and   liquors,  and  providing  penalties   for 
violations  thereof. 

Ee  it  enacted  by  the  General  Assembly  of  the  Commonwealth  of  Kentucky: 
Section   1.     That  it  .shall  be  unlawful  for  any  person,  persons,  firm  or 
corporation  within  this  State  to  manufacture  for  sale,  produce  for  sale,  ex- 
pose for  sale,  have  in  his  or  their  possession  for  sale  or  to  sell  any  article 


1  Figs.    29    and    29a    from    "Certified    Milk    Production"     by    the    autlior,    i)ubli.slied 
in  The  Milk  Trade  Journal,  June,   1913. 


INFANT   FEEDING.  103 

of  food  or  drug  which  is  adulterated  or  misbranded  within  the  meaning  of 
this  act;  and  any  person  or  persons,  firm  or  corporation  who  shall  manu- 
facture for  sale,  expose  for  sale,  have  in  his  or  their  possession  for  sale  or 
sell  any  article  of  food  or  drug  which  is  adulterated  or  misbranded  within 
the  meaning  of  this  act,  shall  be  fined  not  less  than  ten  dollars  nor  more 
than  one  hundred  dollars,  or  be  imprisoned  not  to  exceed  fifty  days  or  both 
such  fine  and  imprisonment.  Provided,  that  no  article  of  food  or  drug  shall 
be  deemed  misbranded  or  adulterated  within  the  provisions  of  this  act  when 
intended  for  shipment  to  any  other  State  or  country,  when  such  article  is 
not  adulterated  or  misbranded  in  conflict  with  the  laws  of  the  United 
States;  but  if  said  article  shall  be  in  fact  sold  or  offered  for  sale  for 
domestic  use  or  consumption  within  this  State,  then  this  provision  shall  not 
exempt  said  article  from  the  operations  of  any  of  the  other  provisions  of 
this  act. 

Sectiox  2.  That  the  term  food,  as  used  in  this  act,  shall  include  every 
article  used  for  or  entering  into  the  composition  of  food  or  drink  for  men  or 
domestic  animals,  including  all  liquors. 

Section  3.  For  the  purpose  of  this  act,  an  article  of  food  shall  be 
deemed  misbranded : 

First.  If  tlie  package  or  label  shall  bear  any  statement  purporting  to 
name  any  ingredient  or  substance  as  not  being  contained  in  such  article, 
which  statement  shall  not  be  true  in  any  part;  or  any  statement  pur- 
porting to  name  the  substance  of  which  such  article  is  made,  which  state- 
ment shall  not  give  fully  the  name  or  names  of  all  substances  contained  in 
any  measurable  quantity. 

Second.  If  it  is  labeled  or  branded  in  imitation  of  or  sold  under  the 
name  of  another  article,  or  is  an  imitation  either  in  package  or  label  of 
another  substance  of  a  previously  established  name;  or  if  it  be  labeled  or 
branded  so  as  to  deceive  or  mislead  the  purchaser  or  consumer  with  respect 
to  where  the  article  was  made  or  as  to  its  true  nature  and  substance  or 
as  to  any  identifying  term  whatsoever  whereby  the  purchaser  or  consumer 
might  suppose  the  article  to  possess  any  property  or  degree  of  purity  or 
quality  which  the  article  does  not  possess. 

Third.  If  in  the  case  of  certified  milk,  it  be  sold  as  or  labeled  "certified 
milk,"  and  it  has  not  been  so  certified  under  the  rules  and  regulations  by 
any  county  medical  society,  or  if  when  so  certified,  it  is  not  up  to  that 
degree  of  purity  and  qualitj'  necessary  for  infant  feeding. 

In  a  local  Louisville  court,  conviction  and  fine  was  obtained 
in  1908  of  a  dairyman,  under  the  State  Pure  Food  Laws,  who 
had  sold  milk  labeled  "Certified  Milk,"  which  had  not  been 
certified  to  by  the  Jefferson  County  Milk  Commission,  the  pros- 
ecution being  because  of  misbranding  and  a  tendency  to  deceive 
the  public. 


104 


THE   DISEASES   OF   CHILDREN. 


Certified  Milk  is  clean,  cold  milk  which  has  been  produced  in 
a  scientific  manner,  under  rules  laid  down  by  a  Medical  Milk 
Commission,  from  a  tuberculin  tested,  healthy  herd,  in  properly 
constructed,  clean  barns,  by  clean,  healthy  milkers,  in  sterile 
vessels,  cooled,  and  bottled  immediately  in  sterilized  bottles,  iced 


Fig.   30. — Certified   mills  bottle.      Stand- 
ard  cap,    protecting   mouth   of   bottle. 


Fig.      31. — Certified      milk      in      special 
glasses    for   lunch    counter    trade. 


and  kept  cold  until  delivered.  Milk  cannot  be  produced  in  this 
manner  and  sell  for  the  same  price  as  market  milk,  produced 
in  dirty  surroundings  and  delivered  to  a  city  distributor  in  ten- 
gallon  cans  and  then  bottled  or  peddled  from  these  cans  from 
open  measures.  The  bacterial  content  of  Certified  Milk  can 
easily  be  kept  below  the  limit  of  10,000  per  cc.  while  market 
milk  is  rarely  found  with  a  count  of  less  than  100,000  per  cc.^ 
Excretion  of  Foreign  Matter  in  Milk. — Inflammatory  condi- 
tions of  the  udder  may  result  in  contamination  of  the  milk  by 
the  presence  of  pus  and  microorganisms  from  the  affected  parts. 
Certain  foods  may  cause  a  decided  odor  as  w'ell  as  taste  to  cow's 


1  The  Methods  and  Standards  for  the  Production  and  Distribution  of  "Cer- 
tified Milk"  were  adopted  by  the  American  Milk  Commissions,  at  the  meeting  over 
which  the  author  had  the  honor  of  presiding,  held  in  Louisville,  May  Ist,  1912, 
So  important  are  these  rules  they  are  reproduced  in  full  in  the  Appendix. 


INFANT   FEEDING.  105 

milk,  as  when  they  are  fed  on  jjarlic  or  lupines,  the  latter  im- 
parting a  bitter  taste  to  the  milk. 

Changes  in  Milk  Produced  by  Bacteria  and  Other  Micro- 
organisms.— The  commoner  and  well-known  changes  which  oc- 
cur in  milk  as  the  result  of  the  action  of  bacteria  and  other 
microorganisms  are  as  follows:  The  souring  of  milk,  with  curd- 
ling, due  to  action  of  the  lactic  acid  bacteria ;  the  putrefaction  of 
milk,  with  production  of  various  odors;  the  coloring  of  milk; 
the  production  of  ropy  milk. 

The  fermentation  caused  by  the  lactic  acid  bacteria  in  milk, 
kept  at  ordinary  temperature,  is  well  known.  The  result  of  this 
fermentation  is  souring  and  curdling  of  the  milk,  and  all  other 
bacterial  changes  are  temporarily  stopped.  As  a  result  of  the 
infection  of  the  milk  by  other  organisms,  abnormal  fermenta- 
tions take  place,  causing  changes  in  the  color,  odor  and  taste 
of  the  milk.  A  blue  discoloration  of  the  milk  is  due  to  its  con- 
tamination by  bacteria,  known  as  the  Bacillus  Cyanogenes,  and 
they  exert  their  peculiar  effect  only  after  the  milk  has  become 
sour.  Others  describe  a  red  milk,  but  this  can  usually  be  traced 
to  a  cow  with  diseased  or  injured  udders.  Slimy  or  ropy  milk  is 
due  to  the  organism  known  as  B.  lactis  viscosus,  and  is  found 
in  the  water  supply  of  the  place. 

The  first  few  drops  of  milk  from  a  healthy  udder  may  con- 
tain a  few  bacteria,  but  the  rest  of  the  milk  direct  from  the 
udder  should  be  sterile.  Milk  is  one  of  the  best  culture  mediums 
and  it  may  readily  become  contaminated  from  the  air,  the  cow's 
skin,  hair  and  udder,  the  milker's  hands  or  clothes,  or  the  uten- 
sils with  which  the  milk  comes  in  contact.  A  clean,  cold  milk, 
from  a  healthy  herd,  will  remain  safe  until  consumed  if  handled 
properly.  The  chief  aim  being  to  keep  dirt  out  of  the  milk,  and 
as  much  comes  from  the  cow's  skin  and  tail,  the  buckets  which 
have  a  small  opening  at  the  top  and  more  at  the  side  than  in  the 
middle,  allow  the  milk  to  be  drawn  into  it  easily  and  prevent  the 
dirt  and  hair  dropping  into  it. 

If  milk  properly  produced  and  handled  has  been  cooled  di- 
rectly after  milking  to  45°  F.,  and  kept  at  this  temperature,  the 
bacteria  per  cubic  centimeter  (20  drops)  should  not  exceed 
10,000,  while  ordinary  market  milk  will  contain  from  500,000 


106 


THE   DISEASES   OP    CHILDREN, 


to  several  million  per  cubic  centimeter.  Clean  milk,  cooled  and 
kept  cold,  will  not  have  a  great  increase  in  bacterial  content  at 
the  end  of  several  days,  and  it  can  be  found  sweet  at  the  end  of 


Fig.  32. — Gurler  milk  pail.  Gauze  fits 
over  opening  with  layer  of  cotton 
between. 


Fig.    33. — Hooded    milk    pail. 


Fig.   34. — Certified  milk  shipping  cases.      Standard  cap   and   seal   on   bottles. 


a  number  of  days.  I  have  drank  such  milk  kept  in  this  way 
when  21  days  old,  and  milk  sent  to  the  Paris  Exposition  in  1900 
from  Illinois,  New  Jersey  and  New  York,  was  sweet  at  the  end  of 
14  days.  This  milk  had  been  kept  cold,  and  was  clean  at  the 
first  milking.  In  the  Summer  of  1910  on  a  trip  to  Europe  we 
used  Certified  Milk  from  Louisville  and  drank  the  last  quart 
which  was  perfectly  sweet  sixteen  days  after  milking. 


INFANT    FEEDING. 


107 


Fig.  34a. — Felt-lined  Lox  with  removable  zinc  container,  used  in  Kentucky  milk 
inspection  work,  for  collecting  samples  of  original  bottles.  Larger  boxes,  made 
on  the  same  style,  are  used  for  shipping.  This  box  is  so  constructed  as  to 
maintain    a   temperature   of   from    1   to   2°    C,   for   24  hours. 


Fig.  34b. — Box  used  in  collecting  samples  of  bulk  milk,  w'ater,  and  samples  of  milk 
from  the  various  processes  in  the  dairy  and  milk  depot.  Made  of  wood  and 
felt  lining  and  an  inside  copper  tank.  The  copper  tank  contains  a  wire  basket 
in  several  partitions,  for  holding  20  ordinary  test-tubes.  On  either  side  of  the 
basket  is  a  copper  lid,  and  the  ice  is  put  under  the  copper  lid.  The  ends  of 
the  tubes  extend  into  the  iced  water.  The  wrapped,  sterile  pipettes  are  shown, 
and  as  each  pipette  is  used,  it  is  put  on  the  opposite  side  of  the  box.  The 
copper  tank  can   be  removed  and  sterilized. 


Note — Boxes  described  in  Figs.  34a  and  34b  designed  and  used  in  the  milk 
inspection  work  of  the  Food  and  Drug  Department,  Kentucky  Agricultural  Experi- 
ment  Station.      Photograph   furnished  by   R.   M.   Allen,    Head  of   Dpjjartment. 


108  THE   DISEASES   OP    CHILDREN. 

The  number  of  bacteria  in  milk  free  from  preservatives  is 
a  direct  indication  of  the  cleanliness  employed  at  the  dairy  in 
the  production  of  the  milk,  the  temperature  at  which  it  has  been 
kept  and  its  age. 

Standards  of  bacterial  contents  are  being  adopted  in  many 
of  the  large  cities.  Certified  milk  has  a  limiting  standard  of 
10,000  per  cc. ;  inspected  milk  100,000  per  cc.  (50,000  per  cc. 
in  Louisville),  and  several  cities  for  market  milk  500,000.  Hence 
the  bacterial  count  of  milk  is  a  most  important  procedure. 

Market  Milk. — Cow's  milk,  to  be  fit  for  consumption  by 
infants  and  children  should  answer  the  following  requirements: 
It  should  be  clean;  from  a  healthy  herd  which  has  been  tuber- 
culin tested;  cooled  immediately  after  milking;  bottled  at  once 
and  sealed ;  contain  no  preservatives ;  be  of  standard  and  definite 
chemical  analysis  and  kept  cold  until  delivered  to  the  consumer. 

Ordinary  city  market  milk  is  not  fit  for  infant  feeding.  It  is 
shipped  to  the  city  in  large  cans,  hauled  through  the  streets  in 
an  uncovered  wagon,  to  the  central  distributing  station,  there 
bottled  (usually  in  unclean  bottles)  and  distributed,  no  ice  being 
ever  near  it.  Some  bottle  the  milk  in  delivery  wagons  from 
large  cans,  the  bottl&s  being  dusty  and  unsterilized.  This  milk 
contains  many  million  bacteria,  and  rapidly  sours  in  warm 
weather,  even  if  kept  on  ice. 

Milk  from  cows  kept  on  distillery  waste  or  slop,  or  brewers' 
grain  or  ensilage  in  any  state  of  putrefaction  or  fermentation, 
is  unfit  for  consumption.  Cows  so  fed  suffer  from  a  diarrhea, 
and  the  stables  housing  them  are  filthy  beyond  description. 
Milk  produced  in  such  barns  contains  myriads  of  bacteria. 

Tuberculosis. — Since  Koch  advanced  his  dictum  in  1901  that 
bovine  tuberculosis  was  not  transmissible  to  man,  scientists  of 
the  world  have  been  at  work  to  disprove  it.  This  has  unques- 
tionably been  done.  Undoubted  cases  of  direct  transmission 
have  been  recorded  by  Jensen,^  a  few  of  which  may  be  men- 
tioned : 

1.  The  17-year-old  daughter  of  Prof.  Gosse  died  of  abdominal  tuber- 
culosis after  drinking  milk  from  cows  affected  with  udder  tuberculosis. 
Other  sources  of  infection  could  not  be  discovered. 


J  Jensen's  Milk  Hygiene. 


INFANT   FEEDING.  109 

2.  Oliver's  observation  concerns  one  of  the  best-proved  cases  of  trans- 
mission by  milk.  In  a  boarding  school  12  young  girls  became  ill  with 
signs  of  intestinal  tuberculosis  and  five  of  them  died.  All  came  from 
healthy  families  and  no  source  of  infection  was  found  but  one  cow  which 
supplied  milk  for  the  school,  and  was  shown  to  be  affected  with  tuber- 
culosis of  the  udder. 

3.  Demme  has  reported  the  following:  In  the  children's  hospital,  Bern, 
four  children  died  of  intestinal  and  mesenteric  glandular  tuberculosis.  He 
was  able  to  exclude  all  other  sources  of  infection  and  to  prove  that  the 
milk  came  from  tuberculous  cows. 

4.  Hills  tells  of  a  21-months-old  child  that  was  affected  with  intestinal 
tuberculosis  three  months  after  making  an  eight-day  visit  to  an  uncle 
where  it  had  drank  the  milk  of  a  cow  having  advanced  tuberculosis.  The 
child  died  of  tuberculosis.  Other  sources  of  infection  were  excluded  and 
another  child  fed  only  with  sterilized  milk  remained  healthy. 

5.  Ernst  reports  that  three  children  of  the  same  family  died  of  tuber- 
culosis after  drinking  milk  from  a  cow  that  died  of  general  tuberculosis 
with  udder  involvement. 

Mohler  ^  states  that : 

The  finding  of  the  bovine  type  of  tubercle  bacillus  in  human 
lesions  is  the  most  direct  and  positive  proof  that  tuberculosis 
of  cattle  is  responsible  for  a  certain  amount  of  tuberculosis  in 
the  human  family.  Numerous  experiments  with  this  object  in 
view  have  already  proven  this  fact.  Thus  the  German  Commis- 
sion on  Tuberculosis  examined  56  different  cultures  of  tubercle 
bacilli  of  human  origin  and  found  six  which  were  more  virulent 
than  is  usual  for  human  tubercle  bacilli,  causing  marked  lesions 
of  tuberculosis  in  the  cattle  inoculated  with  them,  and  making 
over  10  per  cent  of  the  cases  tested  that  were  affected  with  a 
form  of  tuberculosis  which,  by  Koch's  own  method,  must  be 
classified  as  of  bovine  origin.  ,  The  bacilli,  with  the  exception 
of  a  single  group,  were  all  derived  from  the  bodies  of  children 
under  seven  years  of  age,  being  taken  from  tubercular  ulcers 
in  the  intestines,  the  mesenteric  glands  or  from  the  lungs. 

In  a  similar  series  of  tests  conducted  by  the  British  Royal 
Commission  on  Tuberculosis,  60  cases  of  the  disease  in  the  human 
were  tested,  with  the  result  that  14  cases  were  claimed  by  this 
commission  to  have  been  infected  from  bovine  sources.  Ravenel 
reports  that  of  five  cases  of  tuberculosis  in  children  two  received 


1  Bulletin   14,    Hygienic   Laboratory. 


110 


THE  DISEASES  OP   CHILDREN. 


their  infection  from  cattle.  Theobald  Smith  has  also  reported 
on  one  culture  of  the  bovine  tubercle  bacillus  obtained  from 
the  mesenteric  glands  of  a  child  out  of  five  cases  examined,  and, 
according  to  a  recent  paper  by  Goodale,  Smith  has  recently  been 
at  work  on  seven  other  cultures  from  different  children,  four 
of  which  conformed  to  his  idea  of  tubercle  bacilli  emanating 
from  cattle.  Of  four  cases  of  generalized  tuberculosis  in  chil- 
dren examined  in  the  Biochemic  Division  of  the  Bureau  of 
Animal  Industry,  two  were  found  to  be  affected  with  very  viru- 


Fig.   35. — A   sample  of  the  unsuspected  but  dangerous  tubercular   cow.     Rejected  by 
the  veterinarian   after  test. 

lent  organisms,  which  warranted  the  conclusion  that  such  chil- 
dren had  been"  infected  from  a  bovine  source.  The  Pathological 
Division  of  the  same  Bureau  has  likewise,  out  of  the  nine  cases 
of  infantile  tuberculosis  examined,  obtained  two  cultures  of 
tubercle  bacilli  that  could  not  be  differentiated  from  bovine 
cultures.  In  Europe  so  many  similar  instances  of  bovine  tuber- 
cle bacilli  having  been  recovered  from  human  tissues  are  on 
record  that  it  appears  entirely  proven  that  man  is  susceptible 
to  tuberculosis  caused  by  animal  infections,  and  while  the  pro- 
portion of  such  cases  cannot  be  decided  with  even  approximate 
accuracy,  it  is  nevertheless  incumbent  upon  us  to  recommend 
such  measures  as  will  guard  against  these  sources  of  danger 
when  enforced. 


INFANT   FEEDING.  Ill 

Tuberculosis  is  markedly  prevalent  throughout  the  United 
States  in  dairy  cattle.  It  is  estimated  that  in  certain  sections 
it  affects  from  20  to  60  per  cent  of  the  members  of  all  herds. 
In  Washington  16.9  per  cent  of  1538  cattle  tested  reacted  to  the 
test.  It  is  conceded  by  all  that  local  tuberculosis  in  the  udder 
will  result  in  contamination  of  the  milk  with  tubercle  bacilli, 
and  that  in  other  forms  of  bovine  tuberculosis,  as  of  the  intestine 
and  lungs,  great  quantities  of  bacilli  are  excreted  by  the  dis- 
charges which  may  contaminate  the  milk.  It  has  been  found, 
for  instance,  that  70  per  cent  of  all  milk  examined  in  Washing- 
ton, D.  C,  contained  dirt,  and  microscopic  examination  showed 
it  to  be  fecal  in  character,  hence  the  frequency  of  contamination 
by  tubercle  bacilli. 

Tuberculin  Test.— The  tuberculin  used  in  this  test  is  the  ster- 
ilized and  filtered  glycerine  extract  of  cultures  of  tubercle  bacilli. 
In  the  hands  of  competent  men  it  is  practically  an  infallible 
test,  and  a  cow  which  reacts  to  the  test- should  be  slaughtered  at 
once.  This  should  be  under  State  indemnification,  for  without 
State  aid  the  disease  will  not  be  eradicated. 

If  the  injected  animal  is  normal  the  result  of  the  tuberculin 
injection  will  be  negative,  that  is,  she  will  not  show  a  rise  in 
temperature. 

The  "test"  is  applied  as  follows:  The  temperature  of  the  cow 
is  taken  in  the  rectum  at  two-hour  intervals  for  12  hours  and  the 
variations  noted.  That  night  about  9  p.  m.  the  tuberculin  is 
injected  hypodermatically  in  a  shaved  portion  of  the  skin  of  the 
hip.  The  following  day  the  temperatures  are  taken  again  and 
recorded,  as  nearly  as  possible  every  two  hours,  and  continued 
for  20  hours. 

In  the  markedly  tubercular  a  small  dose  of  the  tuberculin 
may  show  no  reaction.  A  tolerance  is  shown  for  the  tuberculin 
for  six  weeks  after  an  injection. 

A  reaction  may  be  found  in  advanced  pregnancy,  during  the 
oestrum  and  in  concurrent  diseases,  as  inflammations  of  the  lungs, 
intestines  or  uterus ;  or  when  a  sudden  change  is  made  in  the 
feeding  during  J;he  test. 

In  reading  the  temperatures  taken  after  the  test,  a  rise  of  2° 
F.  is  not  noted.     It  should  go  above  103.8°  F.     Cows  reacting 


112  THE   DISEASES   OF    CHILDREN. 

should  be  slaughtered  at  once  and  examined  by  veterinary  ex- 
perts capable  of  detecting  minute  as  well  as  gross  lesions. 
Salmon  concludes  as  follows,  regarding  the  tuberculin  test: 

1.  That  the  tuberculin  test  is  a  wonderfully  accurate  method 
of  determining  whether  an  animal  is  affected  with  tuberculosis. 

2.  That  by  the  use  of  tuberculin  the  animals  diseased  with 
tuberculosis  may  be  detected  and  removed  from  the  herd,  thereby 
eradicating  the  disease. 

3.  That  tuberculin  has  no  injurious  effect  upon  healthy 
cattle.  . 

4.  That  the  comparatively  small  number  of  cattle  which  have 
aborted,  suffered  in  health  or  fallen  off  in  condition  after  the 
tuberculin  test,  were  either  diseased  before  the  test  was  made 
or  were  affected  by  some  cause  other  than  the  tuberculin. 

A  cow  may  be  dangerously  tubercular  as  shown  by  Schroeder  * 
long  before  she  shows  clinical  evidences  of  tuberculosis.  She 
may  not  cough,  may  eat  well,  calve,  and  in  every  way  appear  nor- 
mal, yet  be  excreting  millions  of  bacilli  before  the  presence  of 
tuberculosis  is  determined  by  the  tuberculin  test. 

Epidemics  Due  to  Milk. — Specific  organisms  may  contaminate 
milk  and  cause  epidemics  among  its  users.  Typhoid  fever  is 
more  frequently  spread  through  the  medium  of  water,  next  by 
milk.  Jensen  records  90  epidemics  of  typhoid  in  Copenhagen, 
from  1878  to  1896.  I  have  traced  one  in  Louisville  where  there 
were  54  cases  in  a  small  territory,  44  of  whom  used  milk  from 
one  dairy.  In  one  family  only  one  person  used  unboiled  milk 
and  she  contracted  typhoid.  Typhoid  bacilli  were  demonstrated 
by  the  late  Dr.  Louis  Vissman  in  the  water  used  on  this  dairy- 
man's place  for  can  w'ashing.  Diphtheria  may  be  milk  borne, 
also.  Smithbank  and  Newman  ^  record  100  cases  in  Ashtabula, 
Ohio,  affected  with  diphtheria  in  1894.  Milk  was  delivered  to 
all  by  the  same  dairyman.  A  farm  hand  had  a  sore  throat,  and 
he  had  assisted  at  the  work  of  the  dairy  while  so  suffering. 

Scarlet  fever  epidemics  have  undoubtedly  been  traced  to  milk. 
Touching  this  point  of  epidemics  due  to  milk,  Busey  and  Kober 
gave  a  summary  of  the  epidemics  compiled  by  them  as  follows :  ^ 


>  Bulletin    114,    U.    S.    B.    A.   I. 

*  .Jensen. 

^Hygienic  Laboratory   Bulletin   14,   Marine   Hospital   Service. 


INFANT    FEEDING.  113 

TYPHOID  FEVEB  EPIDEMICS. 

Mr.  E.  Hart  tabulated  50  epidemics  of  typhoid  fever  and  we  have  col- 
lected 88,  making  a  total  of  138  epidemics  traceable  to  a  specitic  pollution 
of  the  milk,  the  main  facts  of  which  are  presented  in  a  subjoined  table. 
In  109  instances  there  is  evidence  of  the  disease  having  prevailed  at  the 
farm  or  dairy.  In  54  epidemics  the  poison  reached  the  milk  by  soakage  of 
the  germs  into  the  well  water  with  which  the  utensils  were  washed  and 
in  13  of  these  instances  the  intentional  dilution  with  polluted  water  is 
admitted.  In  6  instances  the  infection  is  attributed  to  the  cows  drinking 
or  wading  in  sewage-pollutod  water.  In  three  instances  the  infection  was 
spread  in  ice  cream  prepared  in  infected  premises.  In  21  instances  the 
dairy  employees  also  acted  as  nurses.  In  6  instances  the  patients  while 
suffering  from  a  mild  attack  of  enteric  fever,  or  during  the  first  week  or 
ten  days  of  their  illness  continued  at  work  and  those  of  us  who  are  familiar 
with  the  personal  habits  of  the  average  dairy  boy  will  have  no  difficulty 
in  surmising  the  manner  of  direct  digital  infection.  In  one  instance  the 
milk  tins  were  washed  with  the  same  dishcloth  used  among  the  fever 
patients.  In  one  instance  the  disease  was  attributed  to  an  abscess  of  the 
udder,  in  another  to  a  teat  eruption,  and  in  one  to  a  febrile  disorder  in  the 
cows.  Four  were  creamery  cases.  In  one  the  milk  had  been  kept  in  the 
sick  room. 

SCARLET   FEVER   EPIDEMICS. 

Mr.  Hart  collected  15  epidemics  of  milk  scarlatina,  and  we  have  tabulated 
5fl,  making  a  total  of  74  epidemics  spread  through  the  medium  of  the  milk 
supply,  the  details  of  which  will  be  found  in  Table  No.  II. 

In  4l  instances  the  disease  prevailed  either  at  the  milk  farm  or  dairy. 
In  6  instances  persons  connected  with  the  dairy  either  lodged  in  or  had 
visited  infected  houses.  In  one  the  milkman  had  taken  his  can  into  an 
infected  house.  In  20  instances  the  infection  was  attributed  to  disease 
among  the  milch  cows;  in  4  of  these  the  puerperal  condition  of  the  animal 
is  blamed.  In  9  instances  disease  of  the  udder  or  teats  was  found.  In  one 
instance  the  veterinarian  diagnosed  a  case  of  bovine  tuberculosis.  In  6 
instances  there  was  loss  of  hair  and  casting  of  the  skin  by  the  animal.  In 
No.  68  the  cattle  were  found  to  be  suffering  more  or  less  from  febrile  dis- 
turbance. In  10  instances  the  infection  was  doubtless  conveyed  by  persons 
connected  with  the  milk  business,  while  suffering  or  recovering  from  an 
attack  of  the  disease  and  in  at  least  8  cases  by  persons  who  also  acted  as 
nurses.  In  three  instances  the  milk  had  been  kept  in  the  cottage  close 
to  the  sick  room.  In  one  the  cows  were  milked  into  an  open  tin  can  which 
was  carried  across  an  open  yard  past  an  infected  house,  and  in  one  the 
milkman  had  wiped  his  cans  with  white  flannel  cloths  (presumably  infected) 
which  had  been  left  in  his  barn  by  a  peddler.  Two  appear  to  have  been 
instances  of  mixed  infection  of  scarlet  fever  and  diphtheria. 


114  THE  DISEASES  OP   CHILDREN. 

DIPHTHERIA   EPIDEMICS. 

Mr.  Hart  collected  7  epidemics  of  milk  diphtheria  and  we  have  added  21 
more.  In  10  of  these  28  instances  diphtheria  existed  at  the  farm  or  dairy, 
and  in  10  instances  the  disease  is  attributed  directly  to  the  cows  having 
garget,  chapped  and  ulcerative  affections  of  the  teats  and  udder,  while 
in  one  the  cows  were  apparently  healthy  but  the  calves  had  diarrhea.  In 
one  case  one  of  the  dairymaids  suffered  from  a  sore  throat  of  an  erysipe- 
latous character,  and  in  one  the  patient  continued  to  milk  while  suffering 
from  diphtheria.  In  one,  one  of  tlie  drivers  of  the  dairy  wagons  was  suf- 
fering from  a  sore  throat. 

Care  of  Milk  in  the  Home. — But  little  care  is  taken  of  milk 
in  the  home  of  the  consumer.  Many  homes  do  not  have  ice  either 
in  winter  or  summer  and  it  is  entirely  impossible  to  keep  milk 
sweet  in  summer  without  ice. 

The  average  time  for  delivery  of  milk  in  the  city  is  from  4.30 
a.  m.  to  6  a.  m.  It  is  left  upon  the  door  step  or  shelf  by  the 
kitchen  door,  frequently  in  summer  in  the  sun,  from  the  time 
it  rises  until  the  servants  arrive,  when  the  bottles  may  or  may 
not  be  put  on  ice  at  once.  Among  the  poorer  classes  the  milk- 
man rings  a  bell  from  his  wagon  and  the  customer  comes  out 
with  an  open  bucket  and  the  milk  is  drawn  from  a  can  which 
has  been  hauled  around  the  city,  in  the  sun,  and  without  a  pro- 
tecting cover,  this  milk  having  never  been  aerated  or  cooled. 

Milk  should  not  be  kept  in  uncovered  vessels  or  in  a  refriger- 
ator with  vegetables,  especially  those  which  give  off  an  odor. 

Among  the  well-to-do  the  use  of  a  thermal  bottle,  an  appliance 
for  keeping  hot  things  hot  and  cold  things  cold,  has  been  sug- 
gested as  a  labor  saver  to  keep  the  baby's  milk  warm  at  night. 
By  keeping  milk  warm  for  several  hours  at  a  temperature  of 
95°  F.  to  100°  F.,  bacterial  growth  is  very  rapid  and  the  milk 
entirely  unfit  for  use.  The  sale  of  these  bottles  for  such  purposes 
should  be  prohibited  by  law. 

Recently  a  breast-fed  baby  seven  months  old,  under  my  ob- 
servation, had  been  stationary  in  weight  for  several  weeks, 
and  the  last  week  had  lost  in  weight.  It  was  decided  to  sup- 
plement the  breast  feeding  by  two  bottles  of  modified  milk  a 
day.  This  was  done,  with  a  slight  gain  in  weight  but  a 
report  of  thin  green  stools.     Inquiry  developed  the  fact  that 


INFANT   FEEDING.  115 

one  feeding  at  night  and  the  first  morning  feeding  were  pre- 
pared and  kept  warm  in  a  "thermos"  bottle.  I  had  some  milk 
prepared  as  usual  the  next  night  and  the  bottle  was  not  opened 
until  the  following  morning,  when  some  of  it  was  plated,  and  as 
a  control,  some  of  the  Certified  milk  delivered  the  same  day 
and  from  which  the  sample  in  the  "thermos"  was  prepared,  also 
plated. 

The  Certified  milk  showed  a  count)  of  3400  bacteria  per 
cc,  and  the  milk  in  the  thermos  bottle  1,400,000.  The  child 
improved  at  once  upon  discontinuing  the  use  of  the  thermos 
bottle. 

MORBIDITY  AND  MORTALITY  STATISTICS  AS 
INFLUENCED  BY  MILK.i 

It  has  been  estimated  that  23  gallons  of  milk  are  purchased 
for  each  person  in  the  United  States  each  year.  This  very  great 
consumption  of  one  commodity  must  have  some  influence  on  the 
population,  for  good  or  bad.  As  children  under  one  year  of 
age  are  the  chief  users  of  milk,  it  must  be  to  statistics  we  must 
look  for  an  answer  to  the  question :  Does  milk  have  any  influ- 
ence upon  mortality  statistics? 

The  United  States  Census  Office  reports  a  population  of 
33,757,811.  There  were  545,533  deaths  of  all  ages  and  105,553 
deaths  in  infants  under  one  year  of  age. 

Diarrhea  and  enteritis  caused  the  death  of  39,399  infants 
in  their  first  year  of  life.  These  figures  show  a  large  proportion 
of  the  total  deaths  are  in  infants  under  one  year  of  age,  and 
a  large  proportion  of  these  deaths  are  due  to  digestive  disorders. 
Eager  points  out  that  a  child  consumes  500  quarts  of  milk 
during  its  first  year,  and  practically  to  the  exclusion  of  other 
articles  of  diet,  hence  it  is  safe  to  conclude  that  milk  is  the 
cause  of  the  digestive  disturbances  which  result  fatally.  It 
is  shown  also  that  the  mortality  in  artificially-fed  children  is 
far  greater  than  in  children  nursed  at  the  breast.  Newsholme  ^ 
states  that,  taking  the  whole  first  year  of  life,  the  number  of 


1  Eager :      Bulletin  14,    Hygienic    Laboratory.  2  Loc.  cit. 


116 


THE   DISEASES   OF    CHILDREN. 


deaths  from  epidemic  diarrhea  among  breast-fed  babies  is  not 
more  than  one-tenth  the  number  among  artificially-fed  infants. 

Epidemics  and  tuberculosis  from  a  milk  source  have  already 
been  referred  to.  It  can  readily  be  inferred  that  an  exhaustive 
study  of  the  milk  question  as  it  relates  to  infant  mortality  is 
amply  justified. 

Sterilization  and  Pasteurization. — Milk  brought  to  the  tem- 
perature of  212°  F.  for  15  minutes  is  sterilized;  when  brought 
to  167°  F.  to  170°  F.  for  20  minutes  it  is  Pasteurized,  the  dif- 


r^^ 


Fig.    36. — Castle    Pasteurizer. 


Pig.   37. — Ilygeia   Pasteurizer. 


ference  being  entirely  the  amount  of  the  heat  used.  Sohxlet, 
in  1886,  advised  the  heating  of  milk  for  infant  feeding  and 
described  an  apparatus  for  carrying  this  out  in  the  home. 

"When  it  is  impossible  to  obtain  a  milk  for  infant  feeding 
which  is  known  to  be  clean  and  cold,  or  the  milk  contains  a 
quantity  of  sediment,  and  sours  easily,  it  is  decidedly  best  to 
submit  it  before  feeding  to  sterilization  or  Pasteurization.  Pas- 
teurized milk  means  "heated  milk,"  and  does  not  necessarily 
mean  "clean,  good  or  pure  milk." 

Both  of  these  processes  destroy  bacteria,  but  do  not  entirely 
destroy  the  spores.  After  heating,  unless  the  milk  is  kept  be- 
low 50°  F.  these  spores  germinate,  and  a  new  strain  of  bacteria 
are  produced  which  multiply  rapidly.  The  germs  most  fre- 
quently found  in  milk  are  the  tubercle  bacillus,  typhoid  bacillus, 
Klebs-Loeffler  bacillus,  the  pyogenic  cocci  and  the  virus  of  foot 


INFANT   FEEDING.  117 

and  mouth  disease  of  cattle.  These  are  all  killed  at  even  a 
lower  temperature  than  107°  F.,  if  maintained  long  enough. 

The  chief  difficulty  in  wholesale  Pasteurization  of  milk  is  its 
being  heated  in  bulk  and  put  in  unsterilized  containers,  either 
bottles  or  cans.  To  be  entirely  effective  it  should  be  first  bot- 
tled, under  as  strictly  cleanly  auspices  as  possible,  then  Pasteur- 
ized, cooled  immediately,  and  kept  cold  until  consumed.  Unfor- 
tunately the  Pasteurization  or  sterilization  of  milk  lulls  one 
into  a  false  feeling  of  security  in  regard  to  it.  The  general 
belief  is  that  the  milk  so  treated  will  keep  indefiiritely  and 
without  ice,  whereas  if  such  a  sample  of  Pasteurized  milk  is 
plated  it  will  be  found  to  contain  many  thousand  bacteria.  It 
has  been  suggested  by  the  New  York  City  Milk  Committee's 
report  to  the  Mayor,  that  when  Pasteurized  milk  is  found  to 
contain  50,000  bacteria  to  the  cubic  centimeter  it  should  be 
destroyed. 

The  result  of  a  number  of  counts  made  of  a  commercially- 
Pasteurized  milk  in  Louisville  showed  an  average  of  200,000 
bacteria  per  cubic  centimeter. 

Efifect  of  Heat. — Owing  to  the  lactic  acid  bacteria  being  de- 
stroyed by  heat,  milk  so  treated  does  not  sour,  but  slowly  putre- 
fies. The  growth  of  the  putrefying  bacteria  in  raw  milk  is  in- 
hibited by  the  lactic  acid  bacteria.  The  effect  of  heat  upon  milk 
depends  upon  the  degree  of  heat.  It  to  some  extent  coagulates 
the  albumin  and  renders  the  milk  less  coagulable  by  rennet.  The 
exact  change  which  takes  place  in  milk  after  heating  is  not 
kno\\Ti,  and  there  is  not  sufficient  clinical  data  at  hand  to  posi- 
tively prove  that  heated  milk  is  insufficient  for  the  nutritional 
needs  of  the  child.  ]\Iilk  of  Certified  grade  is  best  for  an  infant. 
Market  milk  unless  it  lias  been  Pasteurized  is  unfit  for  artificial 
feeding  and  Pasteurization  is  preferable  to  sterilization. 

Composition  of  Milk. — The  milk  from  cows  of  different 
breeds  contains  the  same  ingredients,  but  in  different  propor- 
tions, as  shown  by  the  following  table,  the  results  of  quantita- 
tive analysis.^  These  proportions  vary  according  to  the  breed 
of  the  cow,  condition  of  the  cow  and  the  time  and  method  of 
milking. 

1  Winslow   from    Gordon's   Tables. 


118 


THE   DISEASES   OF    CHILDREN, 


DURHAM 

OR 
SHORT- 
HORN 

DEVON 

AYR- 
SHIRE 

HOLSTEIN 
FRE8IAN 

JERSEY 

BVOWN 
SWISS 

com'on 

NATIVE 

Fat    

4.04 
4.34 
4.17 
0.73 

4.09 
4.32 
4.04 
0.73 

3.89 

4.41 
4.01 
0.73 

3.2 
4.33 

3.99 
0.74 

5.22 
4.84 
3.58 
0.73 

4.0 
4.30 
4.00 
0.76 

3.69 

Suffar    

4.35 

Proteid     

Mineral    matter.  .  . 

4.09 
0.76 

Leach  ^  gives  the  following  analyses  showing  the  composition 
of  milk  of  the  human  and  a  number  of  different  animals: 


800 


200 


200 


32 


KIND 
OF   MILK 


Cow's  milk. 
Minimum     . . 
Maximum    . . 

Mean    

Human  milk 
Minimum  . . 
Maximum    .  . 

Mean    

'joat's  milk: 
Minimum  . . 
Maximum    . . 

Mean    

Ewe's   milk: 
Minimum    . .  . 
Maximum    . .  . 

Mean    

Mare's  milk: 

Mean     

Ass's  milk: 
Mean     


SPECIFIC 
GRAVITY 

WATER 

CASEIN 

AI  BU- 
MIN 

TOTAL 
PhO- 
TUDS 

FAT 
1.67 

MILK 
SUGAR 

1.0264 

80.32 

1.79 

0.25 

2.07 

2.11 

1.0370 

90.32 

6.29 

1.44 

6.40 

6.47 

6;i2 

1.0315 

87.27 

3.02 

0.53 

3.55 

3.64 

4.88 

1.027 

81.09 

0.18 

0.32 

069 

1.43 

3.88 

1.032 

91.40 

1.96 

2.36 

4.70 

6.83 

8.34 

— 

87.41 

1.03 

1.26 

2.29 

3.78 

6.21 

1.0280 

82.02 

2.44 

0.78 



3.10 

3.26 

1.0360 

90.16 

3.94 

2.01 

— 

7.55 

5.77 

1.0305 

85.71 

3.20 

1.09 

4.29 

4.78 

4.46 

1.0298 

74.47 

3.59 

0.83 



2.81 

2.76 

1.0385 

87.02 

5.69 

1.77 

— 

9.80 

7.95 

1.0341 

80.82 

4.97 

1.55 

6.52 

6.86 

4.91 

1.0347 

90.78 

1.24 

0.75 

1.99 

1.21 

5.67 

1.036 

89.64 

0.67 

1.55 

2.22 

1.64 

5.99 

0.35 
1.21 
0.71 

0.12 
1.90 
0.31 

0.39 
1.06 
0.76 

0.13 
1.72 
0.80 

0.35 

0.51 


On  the  proteid  the  body  must  depend  for  its  growth  and 
development,  furnishing  the  material  for  repair  of  waste  going 
on  in  the  tissues  as  wxll  as  for  its  growth. 

Allen  -  has  suggested  the  term  proteid  quotient  to  represent 


1  Hygienic    Laboratory    Bulletin    No.    41.      Marine    Hospital    Service. 

2  Journal    American    Medical   Association,    November    14,    1908. 


INFANT   FEEDING,  119 

the  amount  of  proteid  in  quantity  per  pound  per  day  needed 
by  the  child  for  its  nourishment.  He  estimates  this  as  0.04  to 
0.045  of  an  ounce  for  each  pound  of  the  baby's  weight,  and 
gives  the  following  working  figures:  If  the  milk  contains  3.5 
to  4  per  cent  of  proteid,  it  will  be  necessary  to  give  1  to  1.5 
ounces  of  milk  to  the  pound. 

Proteids. — Van  Slyke  ^  and  others  have  made  investigations 
of  the  chemistry  of  milk  which  have  been  of  great  value. 

Our  knowledge  regarding  the  nitrogen  compounds  of  milk 
has  been  very  indefinite,  especially  with  reference  to  their 
nomenclature.  Some  have  named  as  many  as  seven  compounds, 
but  those  most  frequently  described  are  casein  (caseinogen  or 
milk  casein).,  lactalbumin  and  lactoglobulin. 

The  most  important  of  these  is  the  milk  casein  which  is  found 
in  combination  as  calcium  casein,  and  is  that  portion  of  milk 
which  coagulates  in  sour  milk  or  as  the  result  of  acid  or  rennet 
precipitation. 

All  the  elements  necessary  for  nutrition  are  present  in  casein, 
namely,  carbon,  hydrogen,  nitrogen,  sulphur  and  phosphorus. 

Van  Slyke  and  Hart  ^  have  studied  the  action  of  acids,  alka- 
lies, heat  and  rennet  on  calcium  casein.  They  found  that  with 
dilute  acid  there  is  a  combination  of  the  acid  and  the  calcium, 
and  the  casein  is  set  free.  On  the  addition  of  further  acid  the 
casein  molecule  combined  directly  with  the  acid,  forming  a 
salt  of  the  acid.  The  casein  and  the  casein  salts  of  acids  are 
insoluble,  the  coagulum  being  casein  lactate.  The  casein  and 
casein  salts  dissolve  in  excess  of  acid. 

Dilute  alkaline  solutions,  such  as  the  carbonates  of  sodium, 
potassium  and  ammonium  react  with  free  casein  or  its  salts  with 
acids,  and  form  compounds  that  are  easily  soluble  in  water. 

Heat  alone  at  the  boiling  point  of  water  does  not  coagulate 
casein  in  milk.  The  skin  which  forms  on  milk  heated  above 
140°  F.  is  due  to  the  calcium  casein. 

The  most  characteristic  action  of  any  is  that  of  rennet  on 
milk.  Calcium  paracasein  is  coagulated,  the  change  being  a 
physical  one  only.     To  obtain  prompt  action  of  rennet  the  milk 


1  Archives  of   Pediatries,   July,    1905. 

2  Archives  of  Pediatrics,  July,   1905. 


120  THE   DISEASES   OP    CHILDREN. 

must  not  be  alkaline;  it  must  not  be  diluted  with  water;  must 
not  be  heated  over  106°  or  108°  F.  The  rennet  and  the  milk  must 
be  fresh,  and  the  milk  should  not  be  boiled. 

In  ease  of  milk  containing  3.00  to  4.50  per  cent  of  fat, 
Van  Slyke  ^  has  suggested  the  following  formula  for  calculating 
the  amount  of  casein : 

(F-3)  X  0.4X2.1  =  per  cent  of  casein  in  the  milk. 

F.  in  the  equation,  equals  the  number  representing  the  percentage  of  fat 
in  the  milk. 

Lactalhumin  is  not  acted  on  by  rennet,  is  not  coagulated  by 
acids  at  ordinary  temperature,  and  is  coagulated  by  heat  above 
160°  F.  The  ratio  of  calcium  casein  to  lactalbumin  is  given 
as  3.6  to  1.  * 

Lactoglohulin  is  present  in  very  small  quantities  in  milk. 

Van  Slyke  gives  the  following  figures  to  serve  as  a  guide  to 
approximately  figure  the  amount  of  casein  and  albumin  in  milk, 
the  fat  content  being  known : 

Per  ce.nt  of  fat  in  Per  cent  of  cteiii 

normal  milk  and  albumin 

3.0  2.00 

3.5  '  3.10 

4.0  3.30 

4.5  3.50 

5.0  3.65 

5.5  3.80 

6.0  3.95 

Carbohydrates  occur  in  milk  in  the  form  of  milk  sugar  or 
lactose  (Cj2  H,.^  O^i  H2O).  The  souring  of  milk  occurs  as  the 
result  of  the  action  upon  the  lactose  by  the  lactic  acid  bacteria. 
If  the  milk  is  kept  cold  these  bacteria  will  not  propagate  readily. 

The  fat  content  of  milk  is  found  in  homogeneous  emulsion, 
composed  of  small  droplets  or  globules  fairly  similar  in  size. 
The  chief  fats  contained  in  the  fat  mixture  of  milk  are  olein, 
palmitin  and  stearin.  The  fat  readily  separates  from  the 
remainder  of  the  milk,  forming,  on  standing,  a  distinct  deeper- 
colored  layer  above.  The  fat  can  be  artificially  separated  by 
means  of  a  centrifugal  machine  called  the  "separator."  It  has 
been  claimed  by  some  authorities  that  separated  cream  could 


*New  York  Medical  Journal,    May   30,    1908. 


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122 


THE   DISEASES   OF    CHILDREN. 


not  be  reunited  with  the  fat-free  milk  in  the  homogeneous  mix- 
tures as  before  separation,  but  this  has  not  been  entirely  proven. 

The  inorganic  salts  contained  in  the  milk  in  solution  consist 
chiefly  of  lime,  potash,  sodium.  These  can  be  separated  by 
incineration,  and  are  referred  to  as  the  ash. 

The  tables  of  Van  Slyke  and  Babcock  on  preceding  page 
show  the  quantities  of  these  substances  just  enumerated,  in  cow's 
milk. 

Score  Cards. — The  Bureau  of  Animal  Industry,  Department 
of  Agriculture  of  the  Government,  has  suggested  a  method  of 
scoring  dairies,  herds  and  milk,  and  samples  of  these  are  here 
reproduced : 

(United  States  Department  of  Agriculture,  Bureau  of  Animal  Industry, 

Dairy  Division) 
Sanitary  Inspection  of  Dairies 

Owner  or  lessee  of  farm 

Town    State    

Total  No.  of  cows No.  milking Quarts  of  milk  produced 

daily     

Is  product  sold  at  wholesale  or  retail  ? 

If  shipped  to  dealer  give  name  and  address '. 

Permit  No Date  of  inspection 190 . . 


Coics. 

Ck)ndition    (2)     

Health     (8) 

Cleanliness    

Water    supply    

Stables. 

Construction    

Cleanliness    

Light    

Ventilation    (4)    

Cubic  space  per  cow   (3)  . . 

Removal  of  manure    (2)  .  . 

Stable  yard   ( 1 )    

Milk  House. 

Construction   (2)    

Equipment   ^  3 )     

Cleanliness    

Care  and  cleanliness  of 
utensils    

Water  supply  (Temp.  "¥.) 


SCORE 


Perfect        Allowed 


10 

5 
5-20 

5 
5 
5 

7 
3-25 

5 
5 

5 
5-20 


REMARKS 


INFANT   FEEDING. 


]2H 


Milkers  and  Milking. 

Health  of  attendants 

Cleanliness  of  milking.  .  . 
HandUng   the   Milk. 

Prompt  and  efficient  cool- 
ing     

(Temperature  of  milk  "F) 

Storing  at  a  low  tempera- 
ture      

Protection  during  trans- 
portation     


Total  score 


SCORE 


Perfect         Allowed 


5 
10-15 


10 


100 


REMARKS 


Sanitary  conditions  are:    Excellent Good. 

Suggestions  by  inspector   

Signed    


.Fair. 


.  Poor . 


INSPECTOR. 


Sanitary  inspection  of  dairies   (reverse  side). 
Handling  the  Milk. 

Prompt  and  efficient  cooling:     If  prompt    (a),  5;  efficient   (b).  if  50° 
F.  or  under,  5;  over  50°  and  not  over  55°,  4;  over  55°  and  not  over 
60°,  3;  over  60°,  0;  if  neither  prompt  nor  efficient,  0 10 

Storing  at  low  temperature :     If  50°  F.  or  under,  5;  over  50°  and  not 

over  55°,  4;  over  55°  and  not  over  60°,  3;  over  60°,  0 5 

Protection  during  transportation  to  market:     If  thoroughly  protected 

(iced),  5;  good  protection,  4;  partly  protected,  2;  otherwise,  0.  .  . .        5 


SCOBE. 

If  total  score  is  90  or  above  and  each  division  85  per  cent  perfect  or  over, 
the  dairy  is  Excellent   (entitled  to  registry). 

If  total  score  is  80  or  above  and  each  division  75  per  cent  perfect  or 
over,  the  dairy  is  Good. 

If  total  score  is  70  or  above  and  each  division  65  per  cent  perfect  or  over, 
the  dairy  is  Fair. 

If  total  score  is  below  70  and  any  division  is  below  65  per  cent  perfect, 
the  dairy  is  Poor. 

Note.  On  the  reverse  side  are  directions  for  scoring  cows,  stables,  milk 
house  and  milking. 

Care  of  Bottles  and  Nipples. — Definite  and  positive  directions 
must  be  given  the  mother,  and  to  the  nurse,  in  the  mother's 
presence,  as  to  the  care  of  the  bottles  and  nipples,  and  a  bottle 


124  THE   DISEASES   OF    CHILDREN. 

should  be  selected  which  is  most  easy  to  clean.  The  Hygeia 
nursing  bottle  has  a  wide  mouth  and  a  large  nipple,  both  of 
which  are  very  easily  cleaned  and  sterilized.  The  Arnold 
Pasteurizing  bottle  is  difficult  to  clean  because  of  the  narrow 
opening,  it  being  necessary  to  use  a  brush  in  washing.  The 
same  objection  obtains  in  the  Whitehall-Tatum  bottle,  which  has 
a  wide,  flaring  base. 

New  bottles  can  be  annealed  by  placing  them  in  a  vessel  of 
cold  water,  bringing  it  to  a  boil,  allowing  the  bottles  to  remain 
in  the  water  till  cold.     They  crack  less  readily  when  so  treated. 

If  more  milk  has  been  prepared  than  the  baby  will  take  at 
a  nursing,  when  the  child  has  finished,  the  bottle  should  at  once 
be  emptied,  rinsed  with  cold  water,  then  with  hot,  and  filled 
with  soda  solution,  which  is  allowed  to  remain  in  it  until  the 
milk  is  prepared  the  following  day  for  the  next  24  hours.  The 
bottles  are  then  partly  filled  with  soap  and  water,  a  tablespoon- 
ful  of  bird  gravel  is  poured  in  and  the  bottles  each  thoroughly 
shaken,  this  doing  away  with  the  necessity  for  a  brush.  They 
are  then  rinsed  and  boiled  when  they  are  then  ready  for  use. 
They  should  be  kept  standing  bottom  up  until  filled  with  the 
modified  milk. 

Enough  nipples  should  be  at  hand  to  use  a  different  one  for 
each  feeding.  After  a  feeding  they  are  washed,  turned  inside 
out  and  allowed  to  remain  in  a  soda  or  boracie  acid  solution 
and  boiled  with  the  bottles  the  following  day.  Under  no  cir- 
cumstances should  a  long-tube  nursing  bottle  ever  be  used.  It 
is  absolutely  impossible  to  cleanse  the  tube,  and  it  is  a  constant 
source  of  infection. 

The  aperture  in  a  nipple  should  only  be  large  enough  to  allow 
milk  to  escape  from  it,  with  the  bottle  inverted,  in  drops  in 
quick  succession.  If  it  drops  very  slowly  the  opening  is  too 
small,  and  should  be  enlarged  very  little  by  the  point  of  a  hot 
needle.  If  the  milk  runs  in  a  fine  stream  the  opening  is  too 
large  and  the  nipple  should  be  discarded. 

The  bottle  is  stood  in  a  cup  of  hot  water  until  the  milk  is 
about  90°  F.  The  temperature  of  the  milk  can  be  ascertained 
by  allowing  a  few  drops  to  trickle  on  the  back  of  the  hand  or 


INFANT    FEEDING. 


125 


wrist.  The  practice  of  some  nurses  of  drawing  a  few  drops 
from  the  nipple  with  the  mouth  to  learn  the  temperature  of  the 
milk  cannot  be  too  strongly  condemned. 

Modified  Milk  or  Percentage  System  of  Feeding. — Because  of 
the  marked  difference  between  the  amount  of  proteids  of  cow's 
milk  and  mother's  milk,  cow's  milk  must  be  so  altered  as  to 
change  its  fat,  sugar  and  proteid  content  that  it  will,  as  nearly 
as  possible,  be  adapted  to  the  digestive  capacity  of  the  infant 
and  nourish  it  properly.  This  may  be  done  in  several  ways, 
first  by  using  a  definite  percentage,  centrifugal  cream  in  con- 
nection with  skim  milk  and  a  diluent,  and  the  addition  of 
sugar  of  milk  in  order  to  bring  the  carbohydrate  up  to  the 
proper  amount.  Second,  by  diluting  top  milk,  which  is  a  speci- 
fied number  of  ounces  from  the  top  of  a  quart  bottle  of  milk 
which  has  stood  four  hours  in  order  to  allow  the  cream  to 
rise.     Third,  by  dilution  of  whole  milk. 

The  ideal  method  of  milk  modification  is  by  means  of  the 
milk  laboratory  where  a  physician's  prescription  for  a  definite 
amount  of  the  various  ingredients  of  milk  can  be  written  upon 
a  blank,  and  this  filled  at  the  laboratory  as  a  prescription  for 
medicine  is  in  a  drug  store.  The  best  example  of  this  is  the 
"Walker-Gordon  laboratory,  which  has  established  branches  in 
many  of  the  largest  cities  of  the  United  States.  The  following 
is  a  prescription  blank  which  is  used  in  connection  with  one 
of  these  laboratories: 


PER    CENT 

00 

REMARKS 

Fat 

Number  of  feedings    

Milk-Sugar    

Albuminoids    .... 

Amount   of   each   feeding 

Alkalinity    

Heat  at    

Infant's  age    

. .per   cent 
°F. 

Mineral   Matter    

Total   Solids    

..ad 

Infant's  weight    

Water     

100 

Order 
Date 


190 


Signature 


1 26 


THE  DISEASES   OF    CHILDREN. 


The  following  is  the  latest  modified  milk  prescription  card  sug- 
ijested  by  Dr.  Roteh: 

NEW  PRESCRIPTION   CARD   SUGGESTED  BY   DR.   ROTCH   FOR  LABORATORY   USE. 


EXPLANATORY. 


(ii)  Gravity  cream  will 
be  used,  instead  of 
centrifugal  if  or- 
dered. 

(h)  The  maximum 
amount  of  starch 
possible  in  any  pre- 
scription when  used 
as  a  nutrient  is  1.30 
per  cent.  It  re- 
quires 0.75  per  cent 
starch  to  make  the 
precipitated  casein 
finer. 

fc)  One  hour  completely 
dextrinizes   starch. 

(d)  In  case  physicians 
do  not  wish  to  sub 
divide  the  proteids 
the  words  "Whey" 
and  "Casein"  may 
be  erased. 

(e)  It  requires  0.20  per 
cent  of  the  milk  and 
cream  used  to  facili- 
tate the  digestion  of 
the  proteids,  i.e.,  the 
formation  of  a  soft 
curd;  0.40  per  cent 
to  prevent  the  action 
of  rennet,  i.e.,  the 
formation  of  a  tough 
curd. 

(i)  Twenty  minutes  ren- 
ders the  mixture  de- 
cidedly   bitter. 


(a)   Fats 


(h)  Carbohydrates 


'  Lactose    (milk    su- 
gar) 
Maltose    (malt   su- 
gar) 
Sucrose    (cane    su- 
gar) 
Dextrose         (grape 
sugar ) 
L Starch    (b) 


(c)  Dextrinize    

/  7 1   11     +  •  1     \  Whev 

(d)  rrote.ds  I  ^^^^ 


(e)  Sodium   Citrate 


(f)  Peptonize 


PER 
CENT. 


INFANT   FEEDING. 


127 


KXPLANATOBY. 


(g)  It  requires  20  per 
cent  of  the  milk  and 
cream  used  in  modi- 
fying to  facilitate 
the  digestion  of  the 
proteids.  50  per 
cent  of  the  amount 
of  milk  and  cream 
used  suspends  all  ac- 
tion on  the  proteids 
in  the  stomach.  5 
per  cent  of  the  total 
mixture  gives  a 
mildly  alkaline  food. 

(h)  It  requires  0.68  per 
cent  of  the  milk  and 
cream  used  in  modi- 
fying to  facilitate 
the  digestion  of  the 
proteids.  1.70  per 
cent  of  the  amount 
of  milk  and  cream 
used  suspends  all  ac- 
tion on  the  proteids 
in  the  stomach.  0.17 
per  cent  of  tlie  total 
mixture  gives  a 
mildly  alkaline  food. 

(i)  Percentage  figures 
represent  the  pei 
cent  of  lactic  acid 
attained  when  the 
food  is  removed 
from  the  thermostat. 
When  the  lactic  acid 
bacillus  is  used  to 
facilitate  the  diges- 
tion of  the  proteids, 
tiie  percentage  called 
for  represents  the 
final  acidity,  as  the 
process  is  stopped 
by  heat  at  this  point. 


FEB 

CENT. 


(g)  Lime  water - 


Per  cent  of  milk  and 
cream     

Per  cent  of  total  mix- 
ture     


r  Per    cent    of    milk 
(h)  Sodium  Bicarb..  p,rten["oT  totai 


L      mixture 


(i)  Lactic  Acid  Bacillus 


(1)  To  facili- 
tate digestion 
of  proteids. 

(2)  To  inhibit 
the  saprophy- 
tes of  fermen- 
tation. 


128 


THE   DISEASES   OF    CHILDREN. 


EXPLANATORY 


When  tlie  lactic  acid 
bacillus  is  used  to 
inhibit  the  growth 
of  saprophytes,  the 
acidity  may  subse- 
quently increase  to 
a  variable  degree,  as 
the  bacilli  are  left 
alive.  0.25  per  cent 
lactic  acid  just 
curdles  milk.  0.50 
per  cent  gives  thick 
curdled  milk.  0.75 
per  cent  separates 
the  milk  into  curds 
and  whey. 


PER 
CENT. 


When  the  lactic  acid  bacillus  is  not 
called  for  in  the  prescription,  heat 
at °F 

Number  of  feedings    

Amount   at   each    feeding    oz. 


A  modifying  laboratory  has  been  in  operation  in  connection 
with  the  experiment  station  of  the  Kentucky  Agricultural  Col- 
lege of  Lexington,  Ky.,  for  several  years,  and  the  distributing 
plant  of  certified  milk  in  Louisville,  and  the  Babies'  Milk  Fund 
Association  each  operate  a  laboratory. 

To  obtain  a  proper  conception  of  milk  modification  it  is  posi- 
tively necessary  for  one  to  think  of  a  milk  mixture  as  presenting 
a  given  percentage  of  the  principal  ingredients  of  milk,  namely, 
fat,  sugar  and  proteid,  and  not  of  how  many  ounces  it  takes 
to  make  a  certain  solution  or  how  many  times  a  given  quantity 
of  milk  is  to  be  diluted.  One  must  think  in  percentages  and  not 
in  ounces.  He  must  remember  that  the  basis  of  all  prescription 
modification  is  the  average  analysis  of  mother's  milk  and  cow's 
milk. 

Dr.  T.  M.  Rotch  of  Boston  first  suggested  the  establishment 
of  milk  laboratories,  and  to  him  and  the  Messrs.  Walker  and 
Gordon  are  due  the  developments  along  this  line. 

The  home  modification  may  be  accomplished  in  various  ways, 
some  more  or  less  complicated,  all,  however,  having  the  same  end 
in  view,  that  of  combining  cream,  milk  sugar  and  diluent  in 
such  proportions  that  when  analj'zed  it  will  show  a  result  sim- 
ilar to  an  analysis  of  mother's  milk. 

Before  any  prescription  for  modified  milk  is  given,  the  milk 
to  be  used  should  be  examined  for  the  amount  of  fat  content, 


INFANT   FEEDING. 


129 


<CZ3f 


the  proteid  in  practically  all  grades  of  milk  being  from  3.2  to 

4  per  cent. 

Estimate  of  Fat  Percentage. — In  almost  any  community  can  be 

found  a  Babcoek  milk  tester,  a  centrifugal 
apparatus  for  the  estimation  of  butter  fat 
in  milk.  In  the  graduated  bottle  of  the 
tester  is  poured  16.5  cc.  of  milk,  to  this  is 
slowly  added  17.5  cc.  of  commercial  sul- 
phuric acid  (specific  gravity  of  1.82),  the 
bottle  being  gently  agitated  as  it  is  poured 
in.  The  milk  is  curdled,  but  agitation  dis- 
solves the  curds.  Hot  water  is  then  added 
as  far  as  the  beginning  of  the  tube  end  of 
the  bottle.  It  is  then  placed  in  the  machine 
and  revolved,  the  number  of  revolutions  to 
be  employed  per  minute  being  marked  on 
the  cover  of  the  tester.  More  water  is 
added,  half  way  of  the  tube,  and  centrifu- 
gated  again  for  two  minutes.  Water  is 
again  added  to  the  line  indicated  on  the 
scale  and  centrifugated  for  two  minutes. 
The  fat  has  completely  separated  now  and 
occupies  the  top  of  the  column.  This  is 
read,  the  highest  and  lowest  parts  of  the  col- 
umn of  fat  marking  the  limits  of  the  fat 
percentage. 

A  very  rich  milk  is  not  often  found  in 
cities.  If  an  analysis  is  not  possible,  aver- 
age milk  may  be  considered  to  contain  from 
3.5  to  4  per  cent  of  fat,  4  per  cent  of  sugar 
and  4  per  cent  proteid. 

Top  Milk. — An  average  milk,  if  allowed  Fig.  38— Babcoek  butter 
to  stand  for  hours  in  a  quart  bottle  on  ice,  "'  ^'^^*' 

will  yield  in  its  top  20  ounces  5.8  per  cent  of  fat;  the 
top  16  ounces  7  per  cent  fat;  the  top  9  ounces  11.5 
per  cent   fat;   the   top   6   ounces   16.8   per   cent,   and   the   top 

5  ounces  19.2  per  cent  fat,  and  by  diluting  these  top  milks 
almost    any    percentage    of    fat,    proteid    and    sugar    can    be 


130 


THE  DISEASES  OP   CH1I-.DKEN. 


obtained.  It  should  be  remembered,  however,  that  the  proteid 
in  a  16-ounee  top  milk  is  the  same  as  in  whole  milk,  viz.,  4  per 
cent.  The  chief  thing  to  remember,  then,  is  that  the  top  16 
ounces  contain  7  per  cent  fat  and  4  per  cent  proteid,  and  the 
top  9  ounces  11.5  to  12  per  cent  fat  and  4  per  cent  proteid. 
The  proteid  content  can  be  increased  by  adding  skim  milk 
or  whey.     The  carbohydrate  content  is  in- 

O  creased  by  the  addition  of  sugar  of  milk. 

The  proteid  content  of  the  milk  may  be 
modified  by  the  addition  of  lime  water  or 
carbonate  of  potassium.  Those  alkaline 
agents  limit  the  rennet  action  on  the  milk 
and  smaller  curds  are  formed. 

The  whole  character  of  the  milk  may  be 
changed  by  peptonizing,  which  prepares  the 
casein  for  absorption  and  neutralizes  the 
acid  of  the  stomach. 

If  the  top-milk  method  of  modification  is 
used   the   required    number   of   ounces    are 
dipped  from  a  quart  bottle  by  means  of  the 
Chapin  cream  dipper,  the  milk  having  pre- 
viously stood  for  at  least  four  hours  on  ice. 
By  diluting  top  10-ounce  milk  twice,  that 
is  1  part  top  milk  and  1  part  diluent,  a  for- 
mula is  obtained  of  fat  3.5  per  cent,  sugar 
Fig.  39.— Cha^pin  Cream  2  per  ceut,  proteid  2  per  cent.     By  diluting 
top  9-ounce  milk  four  times,  3  parts  diluent 
and  1  part  of  milk,  the  result  would  give  a  mixture  analyzing  3 
per  cent  fat,  1  per  cent  sugar,  1  per  cent  proteid. 

Thus  a  number  of  formulae  can  be  worked  out  as  follows : 


Fat  4  per  cent  . .  . . 
Sugar  7  per  cent  . . 
Proteid   2  per  cent. 


Dilute  16  ounces  top  milk  twice. 
'2)8%  fat,  4%  sugar, 


4%  fat 


2%'  sugar, 


4%  proteid. 
2%  proteid. 


Ounces 

Top  16  ounces  from  quart   10 

Lime    water    2 

Milk    sugar     1 J 

Water  enough  to  make  20  ounces. 


INFANT   FEEDING.  131 


Fat  3  per  cent  . . 
Sugar  6  per  cent 


Dilute  top  9  ounces  milk  4  times. 

4)  12%  fat,  4%  sugar,  4%  proteid. 


Proteid   1   per  cent   J       3%  fat,  1%  sugar,  1%  proteid 

Ounces 

Top   12  ounces  from  quart   6§ 

Lime    water    2 

Milk    Sugar    1 

Water  enough  to  make  20  ounces. 
Fat   1.50  per  cent    


Sugar  5  per  cent 


Dilute  top  9  ounces  milk  8  times. 

8)     12%  fat,  4%  sugar,  4%,  proteid. 


Proteid  .50  per  cent   J       1.50%  fat,        .50%  sugar,        .50%  proteid. 

Ounces 

Top   12  ounces  milk    2 J 

Lime    water 2 

Milk  sugar    1 

Water  enough  to  make  20  ounces. 

Sugar. — By  adding  1  ounce  of  milk  sugar,  a  little  less  of 
cane  sugar,  to  20  ounces  of  the  solution  the  sugar  content 
is  brought  to  6  per  cent.  Three  level  tablespoonfuls  of  milk 
sugar  equals  1  ounce  in  weight,  or  2  level  tablespoonfuls  of 
cane  sugar. 

Additional  formulae  can  be  found  in  the  appendix. 

Condensed  Milk. — This  milk  is  unfit  for  long-continued  feed- 
ing because  of  its  large  carbohydrate  content  and  small  fat  con- 
tent. It  is  made  by  evaporating,  at  a  low  temperature,  a 
sterilized  cow's  milk  in  large  vacuum  pans  to  about  one- 
fourth  its  volume,  after  which  is  added  about  an  equal  amount 
of  cane  sugar  which  acts  as  a  preservative.  The  unsweetened 
condensed  milk,  termed  "evaporated"  will  quickly  spoil  if  the 
can  is  left  open.  The  following  is  an  analysis  of  condensed 
milk : 

EAGLE   BRAND.  1 

Per  cent. 

Fat    8.8 

Sugar    52 . 2 

Total  proteid    9.3 

Total  solids 72.2 

Ash 1.9 

Water     27.8 


1  Soudern :      Kerley,   Treatment  of  Diseases   of   Children. 


132 


THE   DISEASES   OF    CHILDREN. 


The  following  analyses  are  given  by  Chapin,  from  the  United 
States  Department  of  Agriculture: 


<£> 

, 

00  iH 

tO'^l' 

aid 

i»o 

3   §^- 

<?^ 

5o^- 

%n^ 

5o& 

3    2^^ 

0.^?!; 

CH  ^ 

p>e:» 

2t*S 

CCNPENSED    MILK 

W'^O 

COlH  O 

r-lrH  O 

«>-<« 

.-^^ 

1     §« 

I'ER  CENT. 

t-t^ 

iH 

iH 

P3  a 

M  H  H 

£^« 

o      o  *^ 

H  t«  S< 

0.84 

4.00 

Fat      

.   8.44 

053 

0.60 

0.70 

1.05 

3.50 

Proteid     

.   7.23 

0.45 

0.52 

0.60 

0.72 

0.90 

5.00 

o            (  cane,  41.52  ) 
S"g^''{  milk,  11.69  1 

53.21 

3  33 

3.80 

4.43 

5.32 

6.65 

0.70 

Salts            

.    1.80 
.28.14 

0.11 
95.58 

0.13 
94.95 

0.15 
94.12 

.  0.18 
92.94 

0.22 

86  80 

Water     

91.18 

Owing  to  the  thickness  of  condensed  milk,  and  the  varying 
sizes  of  spoons,  it  is  difficult  to  dilute  condensed  milk  accurately. 
If  a  teaspoonful  of  condensed  milk  is  removed  from  the  can, 
without  allowing  it  to  drip  until  the  spoon  is  level  full,  it  will 
contain  fully  a  teaspoonful  and  a  half.  Hence,  when  measuring 
condensed  milk,  each  spoonful  should  be  allowed  to  drain  until 
it  does  not  drip,  and  its  bottom  scraped  off  on  the  can  before 
adding  the  water.  The  same  spoon  should  be  used  to  measure 
the  water  also. 

The  reasons  for  its  popularity  among  the  poor  is  that  it  is 
cheap,  is  easily  prepared,  and  does  not  spoil  as  quickly  as 
ordinary  milk. 

From  the  analyses  given  it  can  readily  be  seen  that  the  fat 
percentage  in  any  dilution,  even  1  to  8,  is  much  too  small,  and 
the  mixture  in  this  strength,  1  to  8,  is  sickening  sweet. 

As  a  substitute  feeding  in  difficult  feeding  cases  a  weak  dilu- 
tion of  condensed  milk  is  of  great  value,  but  it  does  only  as  a 
temporary  food.  If  used  for  some  time  the  fat  content  can  be 
increased  by  the  addition  of  a  drachm  or  so  of  top  milk,  the 
gradual  resumption  of  cow's  milk  being  attained  in  this  way. 

Kerley  has  suggested  the  administration  of  cod  liver  oil  to 
augment  the  fat  in  condensed  milk. 

Children  fed  on  condensed  milk  are  usually  fat,  l)ut  flabby, 
and  have  little  resistance  to  acute  illness. 


INFANT   FEEDING.  133 

Peptonized  Milk. — In  a  milk  which  has  been  peptonized  the 
proteids  have  been  digested,  converted  into  soluble  peptones, 
and  this  can  be  accomplished  partially  or  completely.  When 
completely  peptonized  the  milk  has  a  bitter  taste.  When  milk 
is  used  in  nutrient  enemas  it  should  be  completely  peptonized, 
as  the  bowel  in  this  part  is  not  a  digesting  organ,  but  an  absorb- 
ing one.  Peptonizing  tubes  (Fairchild)  contain  5  grains  of 
pancreatine  and  15  grains  of  sodium  bicarbonate.  The  contents 
of  one  of  these  tubes  is  dissolved  in  4  ounces  of  water  and 
stirred  into  1  pint  of  fresh  milk.  This  is  then  heated  from 
105°  to  115°  F.  for  20  minutes.  The  process  of  peptonization 
or  digestion  can  be  stopped  by  placing  the  vessel  on  ice  or  by 
bringing  the  milk  quickly  to  a  boil.  If  a  child  is  being  fed 
upon  a  modified  milk  and  it  is  necessary  to  peptonize  it,  the 
contents  of  part  of  a  tube  can  be  added  to  the  bottle  before  feed- 
ing, and  the  bottle  stood  in  a  vessel  of  water  at  a  temperature 
of  120°  F.  and  allowed  to  remain  for  20  minutes.  It  is  then 
cooled  to  the  proper  temperature  for  feeding.  Peptonized  milk 
should  never  be  given  over  a  very  long  period  as  it  relieves  the 
stomach  of  work  whjch  it  should  be  made  to  do.  Completely 
peptonized  milk  has  a  distinctly  bitter  taste. 

Directions  for  Making  Whey. — After  removing  the  cream 
from  a  quart  bottle  of  milk,  the  skimmed  milk  is  heated  to  a 
temperature  not  exceeding  100°  F.  and  removed  from  the  fire. 
To  the  heated  milk  is  added  two  teaspoonfuls  of  essentia  pepsin. 
(N.F.),  or  a  tablespoonful  of  liquid  rennet  or  a  junket  tablet. 
As  soon  as  a  firm  curd  has  formed  this  is  broken  up  with  a 
fork  and  strained  through  a  cheese  cloth  without  pressure. 
It  should  be  cooled  and  kept  on  ice  until  used.  If  milk  or 
cream  is  to  be  added  to  the  whey  after  breaking  up  the  curd 
before  straining,  it  should  be  brought  quickly  to  150°  F..  then 
strained,  otherwise  the  added  milk  will  be  curdled  by  the 
curdling  ferment  remaining  in  the  whey. 

In  certain  difficult  feeding  cases,  fat-free  whey  mixtures  can 
be  used  to  great  advantage.  Practically  all  of  the  casein  has 
been  removed,  the  casein  remaining  being  approximately  .35 
per  cent.  The  following  analyses  from  Van  Slyke  show  the 
food  value  of  whey  obtained  from  various  grades  of  milk : 


134 


THE   DISEASES   OP    CHILDREN. 


WHEY. 

yROM     POOE 

FROM  MEDIUM 

FROM  RICH 

MILK 

MILK 

MILK 

CONTAINING 

CONTAINING 

CONTAINING 

3  PER  CENT  FAT 

4  PER  CENT  FAT 

5  PER  CENT  FAT 

Total   solids    

6.87 

6.96 

7.38 

Fat    

0.28 

0.30 

0.30 

Total   proteids    

0  69 

0.87 

1.03 

Sugar  and  ash   

5.90 

5.79 

6.04 

Water 

93.13 

93.04 

92.62 

When  in  difficult  cases  a  child  has  thrived  for  a  time  upon 
whey,  an  increase  both  in  the  fat  and  proteid  content  can  be 
had  with  an  addition  very  gradually  of  the  milk. 

Southworth  ^  suggests  the  following  method  of  making  whey 
and  of  whey  feeding: 

Method  of  Making  Cream  and  Whey  Mixtures. — Secure  a 
quart  bottle  of  good  average  milk  upon  which  the  cream  has 
risen.  Remove  with  the  Chapin  dipper  the  upper  5  ounces  of 
the  cream  layer,  which,  when  mixed,  will  contain  about  20  per 
cent  of  fat,  and  preserve  this  for  further  use.  Pour  the  re- 
mainder of  the  bottle  (about  27  ounces)  into  a  double  boiler, 
the  lower  portion  of  which  contains  tepid  water,  and  add  1 
tablespoonful  Shinn's  liquid  rennet,  or  1  Hansen's  junket  tablet, 
or  1  tablespoonful  of  Wyeth's  liquid  rennet,  or  2  tablespoonfuls 
of  essentia  pepsin  (N.  F.).  Mix  thoroughly.  Place  a  chemical 
thermometer  in  the  whey  and  heat  slowly  up  to  155° 
(68°  C.)  to  destroy  the  rennet  ferment,  which  otherwise  would 
clot  the  casein  of  the  cream  or  top  milk  when  subsequently  added 
to  the  whey.  Heated  beyond  155°  F.  the  albumin,  part  of  the 
soluble  proteids,  will  be  coagulated  and  the  nutritive  value  of 
the  whey  reduced.  As  soon  as  a  solid  curd  forms  cut  this  cross- 
wise into  small  pieces  with  a  table  knife  to  facilitate  the  escape 
of  the  whey,  and  while  continuing  to  heat  to  155°  F.  use  the 
flat  of  the  knife  blade  to  assemble  and  press  together  the  pieces 
of  curd.  This  increases  materially  the  yield  of  whey,  and  the 
curd  finally  contracts  with  heat  and  manipulation  into  a  rub- 
bery lump  the  size  of  the  palm  of  the  hand.  Straining  through 
a  wire  strainer  now  gives  20  ounces  or  more  of  moderately 
opaque  j^ellowish  whey,  upon  which  but  little  fat  rises  on  stand- 
ing.    Adding  to  20  ounces  of  this  whey  varying  amounts  of  the 

1  Carr :      Pediatrics. 


INFANT    FEEDING. 


135 


top  5  ounces  of  cream  (20  per  cent  fat),  previously  removed, 
will  give  us  a  series  of  formula  suitable  for  most  purposes  where 
cream  and  whey  mixtures  are  required.  By  removing  and  using 
the  top  6  ounces  (17  per  cent  fat)  or  top  7  ounces  (15  per 
cent  fat),  mixtures  may  be  obtained  with  a  lower  fat  per- 
centage ;  or  by  using  more  of  these  top  milks  in  the  mixture 
the  same  amount  of  fat  with  a  larger  proportion  of  casein  in 
the  proteids. 

WHEY  AND  CREAM  MIXTURES,  MADE  FROM  20  PER  CENT  CREAM  (TOP  FIVE 
OUNCES  OF  ONE  QUART  BOTTLE)  AND  TWENTY  OUNCES  OF  WHEY  FORM 
REMAINDER   OF   BOTTLE. 


TAT 

SUGAR 

PROTEID 

PEE  CENT- 

PEE  CENT- 

PEE  CENT- 

AGE. 

AGE. 

AGE. 

20  oz.  whey  +    1  oz.  cream  ( 20  per  cent  fat )  = 

1.00 

5.00 

0.90 

20  oz.  whey  +  U  oz.  cream  (20  per  cent  fat)  = 

1.50 

5.00 

1.00 

20  oz.  whey  +    2  oz.  cream  (20  per  cent  fat)  = 

2.00 

5.00 

1.10 

20  oz.  whey  +  2*  oz.  cream  (20  per  cent  fat)  = 

2.40 

5.00 

1.15 

20  OZ.  whey  +    3  oz.  cream  ( 20  per  cent  fat )  = 

2.75 

5.00 

1.20 

20  OZ.  whey  +  'Si  oz.  cream  ( 20  per  cent  fat )  = 

3.15 

5.00 

1.25 

20  OZ.  whey  +    4  oz.  cream  (20  per  cent  fat)  = 

3.50 

5.00 

1.30 

Any  case  in  which  mild  stimulation  is  desired  an  addition 
of  an  ounce  of  sherry  wine  to  a  pint  of  whey  is  frequently 
desirable  and  of  benefit. 

Ramogen. — Biedert's  Cream  Mixture,  called  Ramogen,  is  a 
preparation  which  in  certain  difficult  feeding  cases  is  of  some 
service  as  a  temporary  food. 

Cow's  milk  can  be  added  to  a  Ramogen-water  mixture  as 
acute  symptoms  have  subsided.  The  following  analyses  have 
been  given  in  various  dilutions: 


CALOEIES 

PERCENTAGE  OP 

RAMOOEN. 

WATER. 

IN    100    cc. 

Proteids. 

Fat. 

Carbohydrates. 

13 

25 

0.52 

1.23 

2.7 

11-12 

26-27 

53-.56 

1.3-1.36 

2.8-3 

10 

30 

0.63 

1.48 

3.1 

9 

33 

0.7 

1.65 

3.46 

8 

35 

0.77 

1.81 

3.8 

7i 

38 

0.81 

1.93 

4. 

7 

41 

0.87 

2.06 

4.3 

6i 

43 

0.93 

2.19 

4.6 

6 

45 

0.98 

2.31 

4.8 

5i 

50 

1.07 

2.54 

5.3 

5 

54 

1.15 

2.72 

5.7 

136 


THE    DISEASES   OF    CHILDREN. 


The  following  analyses  is  given  of  Ramogen  and  whole-milk 
mixtures : 


MIXTURE  OF 


Ramogen. 


Water. 


12.^ 
12 
11 
lU 

loi 

10 

n 

8 

8 
7i 


Milk. 


2 
3 

3.', 
4 

4i 
5 

5i 
6 

(i^ 

7 
7i 


Calories 
IN  100  cc. 

30 

PERCENTAGE  OF 

Proteids. 

Fat. 

Carbo- 
hydrates. 

0.02 

1.39 

2.5 

33 

1.17 

1 .54 

2.8 

35 

1.29 

1.64 

2.88 

37 

1.42 

1.74 

3.0 

39 

1.54 

1.83 

3.12 

41 

1.66 

1.92 

3.24 

43 

1.78 

2.01 

3.36 

45 

1  92 

2.11 

3.5 

47 

2. 

2.19 

3.6 

4!) 

2.18 

2.34 

3.7G 

51 

2.3 

2.4 

3.9 

Calorie. — A  calorie  is  the  amount  of  heat  required  to  raise 
the  temperature  of  1  kilogram  of  water  1°  C,  which  is  about 
equivalent  to  the  amount  required  to  raise  a  pound  of  water 
4°  F.,  and  is  used  as  a  unit  of  measure  of  food  value  as  ex- 
pressed in  terms  of  heat  production. 

Atwater  claims  that: 

One  gram  of  protein  furnishes  4  calories ;  1  pound  furnishes 
1920  calories. 

One  gram  of  fat  furnishes  8.9  calories ;  1  pound  furnishes 
4040  calories. 

One  gram  of  carbohydrate  furnishes  4  calories ;  1  pound 
furnishes  1820  calories. 

It  has  been  suggested  by  Heubner,  Biedert  and  others  that 
during  the  first  year  of  life  a  child  should  receive  about  100 
calories  per  kilo  (2^  pounds)  of  body  weight  in  24  hours,  i.  e., 
for  every  pound  of  its  weight  it  should  receive  sufficient  food 
to  provide  45  calories  of  energy.  During  the  next  three  months 
from  40  to  45  calories  per  pound,  decreasing,  until  at  12 
months  they  consume  32  to  35  calories,  daily,  per  pound  of  body 
weight.  The  following  approximate  schedule  of  infant  require- 
ment is  given  by  Heubner : 


INFANT    FEEDING.  137 

55  calories  for  the  first  week. 

107  calories  for     2  to   12  weeks. 

91  calories  for  13  to  24  weeks. 

83  calories  for  25  to  36  weeks. 

69  calories  for  37  to  44  weeks. 

Pierre  Budin  ^  states  that  average  composition  per  liter  of 
human  milk  is : 

35  grams  of  butter. 
74  -  75  grams  of  lactos;-  or  milk  sugar. 
12  -  14  grams  of  proteicis  of  albuminoids. 
2  grams  of  mineral  salts. 
A  total  of  175  grams  of  solids. 

He  states  the  most  important  substance  in  the  maintenance 
of  the  body  heat  is  butter,  as  it  is  the  constituent  in  milk  which 
contains  the  greatest  number  of  calories.  One  gram  of  butter 
yields  9.3  calories,  and  96  per  cent  of  the  butter  in  milk  is 
utilized  by  the  organism.  Of  the  number  of  calories  repre- 
senting the  average  alimentary  ration  of  an  infant,  that  53  per 
cent,  more  than  half,  come  from  butter.  It  is  estimated  that 
sugar  of  milk  furnishes  29  per  cent,  and  the  albuminoids  18  per 
cent  of  the  total  calories. 

It  has  been  shown  that  the  energy  equivalent  of  1  gram  of 
fat  is  9.1  calories ;  of  1  gram  of  carbohydrate  4.1  calories,  and 
of  1  gram  of  proteid  4.1  calories.  To  calculate  the  calorimetric 
requirements,  determine  from  the  body  weight  the  number  of 
calories  required.  A  child  often  requires  45  calories  per  pound 
or  450  calories,  the  first  of  the  equation  needed. 

An  ounce  of  whole  milk  contains  21  dories. 

An  ounce  of  carbohjdrate  contains  120  calories. 

An  ounce  of  16  per  cent  cream  contains  54  calories. 

One  ounce  of  skim  milk  contains  10  calories. 

One  ounce  of  flour  or  csreal  contains  120  calories. 

One  ounce  of  cereal  water  contains         2  or  3  calories. 

The  number  of  calories  in  the  mixture  can  be  obtained  from 
multiplying  the  number  of  ounces  of  the  various  individual 
ingredients  in  the  mixture  by  the  above  figures  and  adding  the 


1  "The  Nursling." 


138  THE   DISEASES   OP    CHILDREN. 

results  together  to  find  the  energy  quotient  of  the  mixture. 
Divide  the  total  number  of  calories  by  the  number  of  pounds 
and  multiply  this  result  by  2.2  to  get  the  number  of  calories 
per  kilogram. 

Diluents  in  Milk  Formulae. — Because  of  the  fact  that  the 
casein  of  cow's  milk  coagulates  in  such  large  masses  in  the  process 
of  digestion,  it  has  been  suggested  that  the  addition  of  a  cereal 
decoction  will  enable  the  stomach  juices  to  coagulate  the  casein 
mixture  into  the  smaller  flocculi  like  mother's  milk.  In  order  to 
determine  the  capacity  of  an  infant  to  digest  starch,  Kerley 
made  a  large  number  of  stool  examinations  which  showed  con- 
clusively that  the  majority  of  infants  of  any  age  are  able  to 
digest  starch.  He  says  "that  starch  foods  may  be  added  with 
benefit  to  infant-milk  foods  in  a  great  majority  of  cases,  and 
that  they  may  be  used  with  benefit  as  a  substitute  for  these  foods 
in  illness  is  established  beyond  all  question,  both  experimentally 
and  clinically."  The  addition  of  a  dextrinizing  agent  to  any 
of  the  cereal  decoctions  is  to  be  recommended,  among  which  may 
be  mentioned  plain  maltine  and  cereo,  the  latter  made  by  the 
Cereo  Company  of  Tappan,  New  York.  One  teaspoonful  of 
cereo  to  the  pint  of  cereal  gruel  will  completely  dextrinize  it 
and  render  it  more  easy  of  digestion  and  absorption.  As  to 
the  use  of  dextrinizing  agents,  authorities  differ,  Koplik  not 
advocating  their  use,  except  in  cases  in  which  it  is  demonstrated 
that  the  infant  is  not  taking  care  of  the  plain  decoction.  In 
certain  marasmic  infants  in  which  the  percentage  method  of 
feeding  has  failed,  Keller's  method  of  dextrinizing  gruel  may 
be  tried. 

Directions  for  Making  Malt  Soup. — The  following  description 
of  a  malt  soup  is  given  by  Keller,  as  used  at  the  University 
Children 's  clinic  in  Breslau : 

Three  and  a  half  ounces  of  malt  soup  extract  are  added  to 
500  cc.  of  water,  or  1  pint,  and  dissolved.  This  is  solution  No. 
1.  Then  suspend  3  ounces  (in  measure  or  2  ounces  in  weight) 
of  wheat  flour  in  500  cc,  1  pint  of  milk,  so  that  the  solution  is 
quite  uniform.  The  milk  and  flour  solution  is  then  strained 
through  cheese  cloth.  The  solution  of  malt  extract  and  that 
of  the  milk  and  flour  are  mixed  together,  put  into  a  common 


INFANT   FEEDING.  139 

vessel  and  brought  to  a  boil,  being  stirred  constantly  over  a  slow 
fire.  After  about  20  minutes  of  stirring  the  whole  mixture  is 
brought  to  a  boil  to  stop  all  processes  of  digestion.  The  mixture 
is  now  put  up  in  bottles,  each  containing  about  6  ounces,  corked, 
and  kept  cool.  This  mixture  contains  dextrinized  cereal  and 
malt  sugar  in  addition  to  the  proteids  of  the  milk.  Loeflund's 
malt  soup  extract  contains  maltose,  57  per  cent ;  dextrine,  12.4 
per  cent.  Wheat  contains  66.8  per  cent  of  starch,  7.5  per  cent 
of  dextrine,  and  a  small  amount  of  dextrose.  By  the  action  of 
the  ferments  in  the  malt  extracts — principally  diastase — the 
starches  are  converted  into  sugars.  By  this  method  a  number 
of  easily-assimilable  substances  are  introduced  into  the  economy. 
The  action  of  these  processes  on  the  casein  coagulation  seems 
favorable  to  its  assimilation. 

This  malt  soup  preparation  is  recommended  in  subacute 
enteric  catarrh  in  which  milk  in  simple  dilution  is  not  assim- 
ilated. Dr.  Keller  claims  that  the  acid  intoxication  which  is 
present  in  marasmic  infants  yields  to  the  administration  of  this 
malt  soup.  He  found  the  food  of  most  value  in  atrophic  infants 
from  6  to  7  pounds  in  weight,  and  in  infants  who  after  the 
twelfth  month  either  refuse  to  take  milk  food  in  any  form  or 
do  not  thrive  and  are  stationary  in  weight.  After  increasing 
in  weight  and  taking  the  foods  for  two  or  three  months,  it  is 
best  to  take  them  off  the  food  gradually  and  accustom  them  to  a 
modified  milk.  The  chief  difficulty  in  the  way  of  the  use  of 
this  food  is  its  cost. 

Directions  for  Making  Gruels. — Dissolve  a  tablespoonful  of 
cereal  flour  in  small  quantity  of  water,  making  a  smooth  paste, 
add  Mater  to  make  a  quart.  Place  this  in  a  double  boiler, 
stirring  occasionally,  allowing  it  to  cook  for  fifteen  or  twenty 
minutes.  Only  a  double  boiler  should  be  used  as  in  an  open 
vessel  the  gruel  is  easily  scorched.  If  the  cereal  grains  are  used, 
soak  two  tablespoonfuls  in  enough  water  to  cover  them  for  ten 
minutes,  pour  off  this  fluid,  and  add  one  quart  of  water,  pro- 
ceeding as  if  the  flour  was  used.  The  gruel  after  being  boiled 
is  strained  through  a  coarse  meshed  cloth,  or  fine  wire  strainer, 
and  enough  boiled  water  added  to  bring  the  amount  to  a 
quart. 


140  THE   DISEASES   OF    CHILDREN. 

To  dextrinize  the  gruel  cool  it  below  140°  F.,  before  adding 
the  dextrinizing  agent  as  its  diastatic  properties  are  destroyed 
above  that  temperature.  Cool  the  gruel  and  keep  on  ice  until 
used,  making  a  fresh  supply  at  least  every  second  day. 

Ladd  ^  has  shown  that  the  decoction  made  by  using  2  J  ounces 
of  either  barley  or  oat  flour  to  a  quart  of  water,  cooking  for  30 
minutes  and  adding  sufficient  water  to  make  1  quart,  yields 
about  3.50  per  cent  of  starch,  and  is  as  thick  a  solution  as  can 
conveniently  be  strained.  This  3.50  per  cent  decoction  has  there- 
fore been  adopted  as  the  stock  solution  in  the  milk  laboratories. 

On  this  basis  the  amount  of  stock  cereal  decoction  to  be  added 
to  a  mixture  of  modified  milk  to  obtain  any  percentage  of  starch 
can  be  calculated  by  the  formula. 

By  using  3  ounces  of  the  flour  to  a  quart  of  water,  the  stock 
solution  of  cereal  gives  4.5  per  cent  of  starch,  and  if  straining 
the  solution  is  dispensed  with,  higher  percentages  can  be  given 
than  in  the  above  table,  4.50  being  substituted  for  the  denomi- 
nator, 3.50.  An  ounce  of  flour  by  measure  is  practically  the 
same  as  by  weight. 

Junket. — This  is  made  by  coagulating  the  casein  of  cow's  milk 
by  the  addition  of  Fairchild's  essence  of  pepsin,  rennet,  junket 
tablet  or  essentia  pepsin  (N.  F.).  One  teaspoonful  of  pepsin  is 
gently  stirred  into  a  pint  of  fresh,  clean  cow's  milk  and  the 
milk  brought  to  a  temperature  of  115°  F.  for  about  20  minutes. 
It  is  then  removed  from  the  stove  and  when  a  thick  curd  has 
formed  it  is  broken  up  with  a  fork  and  can  be  served  with  or 
without  sugar.     One  teaspoonful  of  sugar  can  be  added. 

Protein  Milk. — The  preparation  of  protein  milk  might  be 
mentioned  to  advantage.  The  buttermilk  from  which  it  is  made 
is  from  a  Pasteurized  skim  milk  containing  1.75  per  cent  of  fat. 
To  one  quart  of  this  is  added  one  ounce  of  buttermilk  from 
some  reliable  dairy.  This  is  allowed  to  stand  for  twelve  hours 
at  a  temperature  of  70°  to  80°  F.,  is  thoroughly  beaten  at  in- 
tervals of  two  to  three  hours  and  then  placed  on  ice  until  used. 
Each  day's  buttermilk  is  made  from  that  of  the  preceding  day, 
a  smaller  amount  of  stock  being  needed  as  time  goes  on.  The 
amount  of  stock  used  is  determined  by  the  degree  of  acidity  de- 

1  .Vrchives  of  Pediatrics,  .Vpril  1908. 


INFANT   FEEDING,  141 

sired.  The  junket  is  obtained  as  follows:  To  two  quarts  of 
skim  milk,  two  Hansen  junket  tablets  are  added.  After  stand- 
ing twenty  minutes  at  100°  F.  the  precipitated  casein  is  strained 
through  a  fine  sieve  with  a  potato  masher.  This  process  of  siev- 
ing is  facilitated  by  adding  buttermilk  to  the  curd  and  is  con- 
tinued until  the  curd  is  thoroughly  broken  into  fine  flakes. 
One  quart  of  buttermilk,  one  quart  of  water,  one  grain  of  sac- 
charin to  the  quart  are  added  to  the  curd  and  the  whole  thor- 
oughly beaten  to  form  a  fine  suspension.  The  requisite  of  the 
food  is  the  fine  floeculent  suspension  of  the  curd  which  depends 
chiefly  on  thorough  sieving.  Boiling  the  precipitated  casein  is 
of  no  benefit.  The  composition  of  this  protein  milk  is  fat  0.8 
per  cent,  sugar  2.4  per  cent,  protein  2.8  per  cent,  and  the  caloric 
value  is  8.5  per  cent  to  the  ounce.  In  administering  the  milk  it 
must  not  be  heated  too  quickly  nor  above  90°  F.,  in  order  to 
prevent  tough  masses  of  casein  forming.  A  large  hole  in  the 
nipple  is  necessary  and  the  feeding  should  be  interrupted  and 
the  bottle  thoroughly  shaken  every  one  or  two  minutes  in  order 
to  keep  the  casein  from  settling  to  the  dependent  part  of  the 
bottle  while  the  fluid  portion  alone  is  being  consumed. 

Albumin  Water. — This  is  made  by  adding  the  white  of  one 
egg  to  a  pint  of  cold  water,  stirring  sufficiently  to  cause  a 
thorough  mixture,  but  not  beating  the  egg  as  it  is  mixed.  Owing 
to  the  fact  that  the  albumin  water  is  a  good  culture  medium  for 
bacteria,  it  is  not  advisable  to  use  this  as  a  substitute  feeding 
in  acute  dyspeptic  or  diarrheal  diseases  in  children. 

Beef  Juice  is  prepared  by  first  cutting  a  piece  of  lean  beef 
into  small  cubes  and  w^hile  held  upon  a  fork  heated  through 
upon  a  hot  plate  or  pan.  The  juice  is  then  expressed  by  means 
of  a  meat  press  or  lemon  squeezer  into  a  warm  vessel.  It  is 
possible  to  obtain  from  4  to  5  ounces  of  beef  juice  from  a  pound 
of  steak.  Beef  juice  may  be  fed  plain  or  in  combination  with 
barley  water  after  salting  to  taste. 

Animal  Broths. — These  may  be  made  from  beef,  chicken,  mut- 
ton or  veal.  A  pound  of  meat  cut  into  small  parts  is  boiled 
for  about  two  hours  in  a  quart  of  water,  enough  water  being 
added  from  time  to  time  to  keep  the  resultant  liquid  at  about 
1  pint.     All  of  the  broths  should  be  strained  thoroughly  through 


142  THE   DISEASES   OP    CHILDREN. 

a  fine  colander  and  allowed  to  cool;  the  fat  which  rises  to  the 
surface  is  then  carefully  removed.  As  a  temporary  food  they 
are  very  good,  especially  in  some  of  the  forms  of  diarrheal  dis- 
eases. They  contain  very  little  fat,  about  1  per  cent  of  proteid 
and  nearly  2  per  cent  extractives. 

Arrowroot  Gruel. — This  substance  has  been  used  as  a  diluent 
for  milk,  as  it  has  the  same  effect  in  breaking  up  the  casein 
as  other  cereal  decoctions.  One  teaspoonful  of  Bermuda  arrow- 
root is  dissolved  in  a  pint  of  water,  allowing  it  to  cook  slowly 
for  20  minutes,  stirring  constantly,  strained  and  allowed  to  cool. 

Kumyss  is  fermented  milk,  and  while  sometimes  taken  by 
older  children  it  is  objected  to  by  a  majority.  Konig  ^  gives 
the  following  analysis  of  kumyss : 

Water     90.44 

Alcohol    1.91 

Lactic   acid ' 0.91 

Milk   sugar 1.77 

Proteid     2.44 

Fat    1.46 

Ash 0.142 

Holt  recommends  the  following  formula  for  its  home 
manufacture : 

One  quart  fresh  milk,  -|  ounce  sugar,  2  ounces  water  and 
piece  of  fresh  yeast  cake  ^  inch  square,  put  into  wired  bottles 
and  kept  at  a  temperature  of  60°  and  75°  F.  for  a  week.  The 
bottles  are  shaken  five  or  six  times  a  day  and  then  put  on  ice. 

Buttermilk. — Fat-free  buttermilk  has  been  used  in  difficult 
feeding  cases  and  those  convalescent  from  severe  enteric  dis- 
turbances with  great  benefit.  Because  of  the  great  bacterial 
content  of  buttermilk  from  churned  milk  it  has  not  been  con- 
sidered a  safe  food,  but  since  the  introduction  of  the  pure  lactic 
acid  bacteria  in  tablet  form  for  the  artificial  manufacture  of 
buttermilk,  its  use  has  become  more  general  and  the  results 
better. 

From  a  quart  bottle  of  milk  the  top  12  ounces  are  removed 
and  12  ounces  of  water  added  in  which  one  lactone  tablet  has 
been  dissolved.     This  is  shaken  and  the  bottle  kept  at  a  tem- 

1  Koplik. 


INFANT   FEEDING. 


143 


perature  of  80  degrees  until  the  milk  is  curdled,  when  it  is  put 
on  ice  and  the  lactic  acid  fermentation  stopped.  This  is  at  first 
given  slightly  diluted  and  finally  undiluted.  Good  buttermilk 
contains  from  0.5  to  1^  per  cent  of  fat;  2.5  to  3.5  per  cent  of 
sugar,  and  about  2.5  per  cent  of  proteid.  The  caloric  value 
of  buttermilk  averages  about  400  calories  per  liter. 

In  certain  acute  intestinal  disorders  the  following  method  of 
preparation  can  be  employed:  In  a  quart  of  buttermilk  is  dis- 
solved two  tablespoonfuls  of  flour  and  3  tablespoonfuls  of  cane 
sugar,  heat  to  boiling,  stirring  constantly,  and  cooled. 

Oatmeal  Jelly. — Two  tablespoonfuls  of  oatmeal,  rolled  oats 
or  Quaker  oats,  or  oat-gruel  flour,  to  1  pint  of  water  cooked  in 
double  boiler  three  hours,  add  water  to  keep  the  amount 
at  1  pint.  Strain  through  a  colander,  allow  to  cool  and  keep 
on  ice.     One  tablespoonful,  level,  of  the  flour  equals  ^4  ounce. 

Scraped  Beef. — A  thick,  lean  steak  is  heated  through  on  a 
hot  griddle.  With  a  sharp  knife  the  browned  surface  is  cut  off 
and  with  a  knife  held  at  right  angles  to  the  meat,  the  pulp  is 
scraped  away,  made  into  a  meat  ball,  again  heated  through 
and  fed  after  salting  to  taste. 


1  level    tbsp.    flour    to    qt.    of 

water    ^ 

2  level    tbsp.    flour    to    qt.    of 

water    

3  level    tbsp.    flour    to    qt.    of 

water 

1  level  coverful  flour  to  qt.  of 

water    

2  level  coverfuls  flour  to  qt.  of 

water 

3  level  coverfuls  flour  to  qt.  of 

water    

4  level  coverfuls  flovir  to  qt.  of 

water    


Barley. 

Legume. 

Oat. 

Wheat. 

<» 

OS 

to 

m 

H 

H 

H 

a 

f- 

t< 

ri 

< 

< 

<. 

» 

K 

a 

CO  ^ 

1% 

11 

U 

go 

BS  « 

H  « 
HO 

SI  o 

«  a 

<  H 

<  K 

<  a 

<  H 

p.  a. 

O  Cu 

"  0. 

y  e- 

p.  0, 

O  d, 

a.  0. 

O  d, 

0.12 

0.60 

0.19 

0.53 

0.12 

0.60 

0.10 

0.62 

0.24 

1.20 

0.39 

1.06 

0.24 

1.20 

0.20 

1.25 

0.30 

1.80 

0.58 

1.59 

0.36 

1.80 

0.30 

1.88 

0.48 

2.40 

0.78 

2.12 

0.48 

2.40 

0.40 

2.50 

0.96 

4.80 

1.56 

4.24 

0.96 

4.80 

0.80 

5.00 

1.44 

7.20 

2.34 

6.36 

1.44 

7.20 

1.20 

7.50 

1.92 

9.60 

3.12 

8.48 

1.92 

9.60 

1.60 

10.00 

144  THE   DISEASES   OP    CHILDREN. 

Percentage  Cereal  Gruels. — The  following  analysis  is  given 
by  the  Cereo  Company  of  gruels  made  from  their  specially-pre- 
pared flours.  The  top  of  the  package  has  been  designed  as  a 
measure  for  the  flour.  Barley,  legume  (made  from  beans), 
oats  and  wheat  are  utilized  for  preparation  of  flours.  From 
the  foregoing  table  can  be  seen  the  strength  of  the  gruel  when 
larger  or  smaller  quantities  of  flour  are   used   in   the   water. 

SYMPTOMS  OF  DISAGREEMENT   OF  MILK  FEEDING. 

Insufficient  Quantity. — Child  will  cry  immediately  the  bottle 
is  empty  and  will  suck  on  its  fists. 

Too  Much  Fat. — Vomiting  will  occur  very  soon  after  a  feed- 
ing; stools  more  frequent  and  thin;  presence  of  lumps  of  a 
soft  material  resembling  curds. 

Too  Much  Sugar. — Thin,  green,  sour  stools  with  gas  passed 
with  each;  an  excoriation  of  buttocks  frequent. 

Too  Much  Proteid. — Colic;  vomiting;  curds  in  action,  fre- 
quently in  large  numbers,  either  large  or  small,  with  much 
mucus  mixed  or  separate.  There  may  be  alternating  diarrhea 
and  constipation. 

Formula  Too  Weak. — Stationary  weight  with  constipation. 

Talbot^  has  shown  "that  the  curds  in  infants'  stools  are 
either  large  curds  containing  a  large  per  cent  of  nitrogen  and  a 
small  per  cent  of  soaps;  and  small  curds  containing  a  low  per 
cent  of  nitrogen  and  a  large  per  cent  of  soaps."  He  concludes 
these  curds  are  composed  of  some  proteid,  probably  casein  or  one 
of  its  derivatives,  which,  on  coagulating,  entangles  the  milk  fat 
in  its  meshes.  The  amount  of  fat  in  the  curds  depends  on  the 
amount  of  fat  in  the  milk,  and  as  the  fat  increases  it  replaces 
the  proteid  in  the  curd.  The  presence  of  large  curds  can  be  in- 
terpreted as  indicating  lack  of  HCl.  "The  small  curds-  are 
composed  mainly  of  fat,  mostly  in  the  form  of  fatty  acids  and 
soaps.  There  is  no  evidence  that  they  contain  casein-like  ma- 
terial, and  they  have,  like  the  normal  stool,  a  low  percentage  of 
nitrogen.  They  represent  the  fat  in  the  stool  rather  than 
protein." 


'  Boston   Medical   and   Surgical  Journal,   January   7,    1909. 
"  Boston  Medical  and   Surgical  Journal,  June   11,   1908. 


INFANT   FEEDING.  145 

The  large  casein  curds  with  shiny  envelope  can  be  prevented 
by  heating  the  milk  to  170°  F.  before  it  is  given. 

Difl&cult  Feeding  Cases. — The  above-named  symptoms  may  be 
present  successively  as  the  ease  progresses  and  each  must  be 
met  by  appropriate  measures.  As  before  stated,  one  must  not 
attempt  to  adapt  a  formula  to  a  certain  age.  Each  child  must 
be  a  law  unto  itself.  A  weak  formula  in  all  its  ingredients  must 
first  be  given,  even  if  the  digestion  has  been  entirely  normal, 
though  it  be  at  the  sacrifice  of  several  ounces  in  the  child's 
weight,  rather  than  upset  the  child's  digestion  by  a  strong  mix- 
ture, and  not  be  able  to  get  it  back  on  a  gaining  formula  for 
some  time. 

The  first  formula  should  contain  less  than  2  per  cent  of  fat 
and  less  than  1  per  cent  of  proteid,  and  this  may  be  increased 
daily  or  every  other  day  until  the  child  appears  satisfied  and 
evidences  a  gain  in  weight.  It  is  the  proteid  content  which  will 
cause  the  most  trouble  with  the  majority  of  difficult  cases,  though 
fat  intolerance  is  frequently  seen.  I  have  had  under  my  care 
one  child  who,  from  six  months  to  one  year  of  age,  could  not 
be  gotten  up  beyond  3  per  cent  of  fat,  the  prescription  upon 
which  she  thrived  best  being  fat,  3  per  cent;  sugar,  6  per  cent; 
proteids,  2  per  cent. 

To  aid  the  digestion  of  the  casein,  and  to  assist  in  its  break- 
ing up  in  small  flocculi,  several  measures  have  been  advocated. 
Poynton  of  London  suggested  the  use  of  citrate  of  soda  in  the 
proportion  of  1  grain  to  the  ounce  of  milk.  He  claims  that 
sodium  paracasein  is  formed  which  is  absorbed  as  a  fluid.  Cot- 
ton of  Chicago  has  advocated  its  use  also.  The  soda  is  not  an 
alkali  but  an  alkali  is  needed  for  the  purpose  of  assisting  in 
breaking  up  of  the  curds,  and  to  favor  the  production  of  hydro- 
chloric acid,  hence  the  importance  of  the  addition  of  lime  water 
to  the  formula.  Rotch  claims  the  soda  decalcifies  the  casein,  it 
is  then  not  affected  by  rennet  forming  with  the  acids  of  the 
stomach,  soft,  friable  flakes  of  the  buttermilk  type. 

The  following  case  is  an  example  of  this  difficult  feeding 
class : 

Child  born  after  normal  labor  of  short  duration ;  mother  primipara,  very 
nervous  temperament,  anemic;  abundant  supply  of  milk  at  first  but  gradual 


146  THE  DISEASES   OP    CHILDREN. 

failure;  history  in  child  of  slight  jaundice;  colic,  crying  all  the  time;  curds 
and  mucus  in  movements;  had  been  taken  off  of  breast  milk  and  given 
successively  malted  milk,  barley  water  and  malted  milk,  barley  water  and 
panopepton,  albumin  water  and  malted  milk,  albumin  water,  Ramogen. 
Five  weeks  old  when  I  saw  it  first;  constant  crying;  tense  abdomen;  given 
2  teaspooufuls  of  olive  oil  and  put  on  a  dextrinized  gruel  and  whey,  equal 
parts,  2  ounces  every  two  hours.  The  first  night  it  slept  all  night,  had 
two  movements,  well  digested.  On  third  day  it  was  given  a  mixture  of 
whey,  2  ounces,  and  barley  water,  J  an  ounce,  and  was  nursed  by  the 
mother  twice,  with  a  bottle  after  each,  when  about  half  quantity  was  taken. 
On  fourth  day  was  put  on  modified  milk  fat  1.5  per  cent,  sugar  G  per  cent, 
proteid  .8  per  cent.  Gained  lOi  ounces  the  first  week  and  in  every  way 
seemed  normal. 

The  history  of  this  case  is  a  counterpart  of  a  number  that 
are  seen,  and  unless  the  child  has  already  developed  into  an 
athreptic  or  marasmic  state  this  plan  will  usually  bring  good 
results. 

At  the  first  sign  of  disagreement  discontinue  the  milk  mix- 
ture and  give  one  of  the  cereal  dococtions;  after  a  few  days  try 
a  small  amount  of  whey  with  the  cereal ;  then  add  milk  gradually. 
If  cow's  milk  in  this  form  cannot  be  assimilated,  try  condensed 
milk  as  a  temporary  food,  beginning  this  with  a  dilution  of  at 
least  1  part  to  20  or  24.  Top  milk  may  very  tentatively  be 
added  to  the  condensed  milk  and  gradually  increased,  and  in  this 
way  get  on  to  a  gaining  formula. 

Care  of  Milk  for  Journey. — One  is  frequently  asked  to  sug- 
gest a  method  of  preparing  milk  for  a  journey.  I  recently  had 
a  box  fixed  for  two  children  starting  for  Mexico.  A  wooden 
box  was  built  around  an  ordinary  galvanized  delivery  tray  hold- 
ing 4  quart  bottles,  a  handle  and  hasp  being  soldered  on.  The 
4  quart  bottles  were  surrounded  with  ice  and  instructions  given 
as  to  change  of  ice  by  car  porters  en  route.  Certified  milk  was 
sent,  and  word  received  from  travelers  at  journey 's  end  reported 
milk  sweet  and  unchanged.  If  a  modified  milk  formula  had 
been  required  for  either  of  these  children  it  could  have  been 
prepared  and  placed  in  nursing  bottles  or  a  quart  Mason  fruit 
jar  with  screw  top,  and  the  bottle  shaken  before  each  feeding 
was  poured  into  the  nursing  bottle. 

Diet  After  the  First  Year. — Milk  should  be  the  basis  of  a 


INFANT   FEEDING.  147 

child's  diet  for  the  first  12  months.  Weaning  (see  page  99) 
should  be  begun  before  the  twelfth  month,  and  artificial  feeding 
be  complete,  or  nearly  so,  at  that  time.  At  10  or  11  months 
of  age  one  feeding  a  day  can  be  given  of  strained  oatmeal,  2  or 
3  tablespoonfuls,  over  which  is  poured  some  of  the  modified 
milk.  With  the  advent  of  the  first  six  or  eight  teeth,  an  occa- 
sional piece  of  toast  or  zwieback  can  be  given  the  child  to 
chew  on. 

Only  one  new  article  of  diet  should  be  given  at  a  time,  for  if 
the  child  takes  two  new  ones  and  is  upset,  unless  passed  undi- 
gested, the  disturbing  cause  would  not  be  known. 

Regularity  of  feeding  should  be  positively  insisted  upon,  and 
the  habit  of  between-meal  eating  ' '  stopped  before  it  has  begun. ' ' 
Nothing  but  water  should  be  given  between  meals.  The  habit 
of  continuing  night  feedings  until  the  second  year  should  never 
be  allowed. 

Too  much  emphasis  cannot  be  placed  on  the  necessity  for 
thorough  and  prolonged  cooking  of  cereals  for  infant  feeding, 
especially  oatmeal. 

While  it  is  a  pleasure  but  few  parents  will  deny  themselves, 
a  young  child  should  not  be  allowed  at  the  table  at  the  family 
meal  times.  The  temptation  to  give  the  child  a  taste  of  this 
or  that  is  too  great  to  be  resisted. 

Fruit  juices  should  be  given  before  the  end  of  the  first  year, 
orange  being  usually  most  enjoyed.  It  should  not  be  given  too 
close  to  a  milk  feeding.  After  the  first  year  prune  juice,  if  not 
too  sweet,  can  be  given. 

The  following  diet  lists  are  suggested  as  a  guide  for  feeding 
after  the  first  year:  The  first  feeding  in  morning  and  last 
feeding  at  night  are  usually  milk,  and  the  child  at  this  age 
requires  more  than  can  be  held  in  the  ordinary  bottle,  which 
is  made  to  contain  8  ounces.  Whitehall-Tatum  Company  manu- 
facture a  12-ounce  bottle,  and  at  my  suggestion  the  Hygeia 
Nursing  Bottle  Company  have  begun  to  manufacture  a  12- 
ounce  Hygeia  bottle,  which  will  be  found  a  great  convenience, 
obviating  the  necessity  of  preparing  two  bottles  for  each  feeding. 

From  Twelfth  to  Fifteenth  Month. — Five  meals  a  day.  The 
first  meal,  6.30  to  7.30  a.  m.,  8  or  10  ounces  of  milk ;  10  a.  m. : 


148  THE   DISEASES   OF    CHILDREN. 

Strained  oatmeal  jelly,  2  or  3  tablespoonfuls  with  4  or  more 
ounces  of  milk  in  addition,  or  soft-boiled  egg  not  oftener  than 
three  times  a  week.  Noon :  Juice  of  half  an  orange.  1  o  'clock : 
Scraped  beef  and  bread  crumbs,  or  rolled  zwieback  or  4  to  6 
ounces  of  animal  broth,  with  zwieback  or  Holland  rusk.  4  p.  m. : 
Bread  and  milk.     7  p.  m. :  bottle  of  milk. 

From  Fifteenth  to  Eighteenth  Month. — To  the  above  list  may 
be  added  the  cooked  fruits,  as  prunes,  not  too  sweet ;  the  inside 
of  a  baked  apple  or  apple-sauce;  thoroughly  cooked-rice;  boiled 
or  baked  potato;  junket;  finely-minced  mutton  chop. 

From  Eighteenth  Month  to  Third  Year. — During  this  period 
other  vegetables  may  be  added  gradually,  as  spinach,  asparagus 
tips,  stewed  celery,  baked  potato,  peas,  beans,  fish,  thin  crisp 
bacon,  minced  chicken  or  turkey,  roast  beef,  cream,  crackers, 
bread  and  butter. 

Sample  diet  list  from  sixteenth  to  eighteenth  month : 

Breakfast,  7  a.  m.  Strained  oatmeal,  2  or  3  tablespoonfuls, 
and  cream,  or  barley  gruel,  and  cream  with  8  ounces  of  whole 
milk. 

Second  Meal,  10.30  a.  m.  Milk  and  stale  bread,  or  cracker, 
rusk  or  zwieback. 

Third  Meal,  1.30  to  2  p.  m.  Any  of  the  following:  Soft-boiled 
egg  (water  boiled  vigorously,  removed  from  stove,  and  egg 
dropped  in  for  two  minutes),  with  broken  toast  or  zwieback; 
(b)  8  ounces  of  animal  broth  (beef,  mutton  or  chicken)  ;  (c) 
a  teacupful  of  junket  with  milk;  (d)  thoroughly-cooked  rice 
and  milk.     Stewed  prunes  can  be  given  with  this  meal. 

Fourth  Meal,  5.30  to  6  p.  m.  Bread  and  milk.  Fruit  juices 
are  given  between  meals,  as  suggested  in  previous  lists. 

To  be  Avoided. — Candy  should  not  be  given  to  children  under 
three  years  of  age,  and  very  sparingly  after  that  time.  Sweets  of 
all  kinds  cause  a  tendency  to  develop  a  pharyngeal  trouble  such 
as  tonsillitis  and  frequent  attacks  of  ''  colds  "  and  bronchitis. 

Proprietary  Foods. — The  fact  that  there  are  upon  the  market 
almost  countless  numbers  of  baby  foods  is  evidence  enough  that 
none  answers  the  requirements  in  all  eases.  These  foods  may  be 
divided  into  three  classes ;  first,  the  so-called  milk  foods  to  which 
water  is  added,  and  those  foods  in  the  form  of  powder  which 


INFANT   FEEDING.  149 

have  been  suggested  as  modifiers  of  milk.  The  latter  are  added 
to  milk  for  their  influence  upon  the  casein.  Second,  the  so- 
called  Liebig  or  malted  foods,  and  third,  the  farinaceous  foods. 
In  the  second  class  the  starches  are  supposed  to  have  been 
entirely  converted  into  soluble  sugars  by  the  diastatic  action 
of  the  malt.  In  the  third  class  but  a  small  portion  of  the  starch 
is  converted  by  the  process  of  cooking. 

Among  the  first  class  may  be  mentioned  condensed  milk  and 
evaporated  cream,  Prof.  Gartner's  mother's  milk  and  Ramogen, 
Mellin's  Food  and  peptogenie  milk  powder.  In  the  second 
group,  the  malted  foods,  are  Nestle 's  food  and  malted  milk.  In 
the  third  class  a  farinaceous  or  dextrinized  food  is  Imperial 
Granum,  which  may  be  temporarily  used  alone  or  in  combina- 
tion with  milk. 

Mellin's  food  is  used  with  milk  as  a  modifier,  it  being  claimed 
that  it  acts  as  an  attenuant  to  the  curds  of  cow's  milk. 

Peptogenie  milk  powder  is  used  with  milk  and  the  mixture 
submitted  to  heat.  By  this  process  the  proteids  are  converted 
into  absorbable  peptones.  Nestle 's  food  and  malted  milk  when 
diluted  are  deficient  in  fat  and  proteid. 

Gavage. — This  method  of  feeding  is  a  valuable  one  in  certain 
classes  of  cases  in  which  a  child  will  not  eat  or  is  too  weak  to 
do  so,  or  in  which  vomiting  occurs  immediately  after  food  is 
taken.  The  same  steps  are  taken  as  in  stomach  washing  (see 
page  82).  The  food  mixture  is  poured  into  the  funnel  and 
when  it  has  been  seen  to  pass  the  glass  tube  connecting  the 
catheter  wdth  the  rubber  tube,  the  catheter  is  comprassed  tightly 
and  quiekly  withdrawn.  Gavage  may  be  performed  with  the 
patient  in  a  recumbent  position  or  held  upright  in  the  nurse's 
lap,  leaning  against  her  shoulder.  The  writer  had  the  pleasure 
of  observing  the  cases  at  the  New  York  Infant  Asylum  when 
an .  interne  there,  reported  by  Dr.  Kerley  in  the  Archives  of 
Pediatrics,  February,  1901.  It  was  found  in  these  cases,  many 
of  them  of  persistent  vomiting,  that  water  or  food  introduced 
into  the  stomach  through  the  tube  was  retained  when  a  very 
much  smaller  quantity  given  by  the  mouth  from  a  spoon  or 
bottle  would  not  be  retained.  Young  children  stand  the  intro- 
duction of  the  tube  without  discomfort,  and  gavage  can  be  used 


150  THE   DISEASES  OF   CHILDREN. 

for  a  very  much  longer  period  of  time  than  rectal  feeding  can 
possibly  be  tolerated.  A  very  weak-modified  milk,  plain  or 
peptonized,  cereal  decoctions,  the  concentrated  foods,  as  pano- 
pepton  and  stimulants,  may  be  given  in  this  way.  In  cases  of 
diphtheria  or  those  wearing  an  intubation  tube,  the  stomach  tube 
is  best  introduced  through  the  nares. 

Rectal  Feeding. — This  method  of  nourishment  is  a  valuable 
one  when  all  others  have  failed,  and  may  be  the  means  of  tiding 
over  a  desperate  case  until  nourishment  can  be  given  in  other 
ways.  ■  The  food  for  administration  in  this  way  should  be  as 
near  as  possible  free  from  fat  and  completely  peptonized.  Com- 
pletely peptonized  or  pancreatized  skimmed  milk,  mixed  with 
albumin  water  of  double  strength,  namely,  the  whites  of  two 
eggs  and  a  pint  of  water,  can  be  used  to  advantage.  This  should 
be  heated  to  about  100°  F.  as  it  loses  several  degrees  of  heat 
in  its  passage  through  the  tube  of  the  fountain  syringe,  if  this 
syringe  is  used  to  insert  it.  The  food  is  best  inserted  through 
a  small-size  short  rectal  tube  (No.  14A)  which  can  be  attached 
to  a  small  rubber  tube  of  the  fountain  syringe,  or  the  fluid  can 
be  injected  with  a  hard  rubber  or  glass  piston  syringe;  care 
must  be  taken  to  invert  the  syringe  to  be  sure  that  all  of  the 
air  is  first  expelled.  The  child  is  placed  upon  its  left  side,  hips 
elevated  by  raising  upon  a  rubber-covered  pillow,  its  thighs 
flexed  upon  its  abdomen  much  as  in  the  Sim 's  position ;  the  tube 
is  anointed  well  with  vaseline  from  a  tube,  and  the  external 
sphincter  also  greased.  The  tube  is  then  inserted  slowly  to  the 
distance  of  9  or  10  inches  and  the  nutrient  enema  slowly  injected. 
Not  more  than  3  ounces  should  be  injected  in  a  child  of  six 
months  of  age,  nor  more  than  6  ounces  in  a  child  of  three 
years  of  age.  After  the  injection  the  tube  is  compressed  and 
quickly  withdrawn,  and  the  child's  buttocks  compressed  firmly 
and  the  child  held  in  the  original  position,  if  possible;  if  not, 
it  is  allowed  to  lie  upon  its  back  with  legs  and  thighs  flexed. 
Tliese  enemas  can  be  given  as  often  as  three  or  four  times  in 
24  hours,  but  if  given  much  oftener  than  this  the  bowel  soon 
becomes  intolerant  and  they  are  expelled  as  soon  as  introduced. 

In  this  connection  might  be  mentioned  the  great  benefit 
obtained  from  the  high  colon  injection  of  water  in  cases  of 


INFANT   FEEDING.  151 

deficient  kidney  excretion,  as  the  absorption  from  the  colon  is 
both  rapid  and  prompt.  The  method  of  Murphy  suggested 
originally  for  use  in  septic  peritonitis  in  both  adults  and  chil- 
dren, viz.,  the  continuous  rectal  injection  may  also  be  employed 
to  advantage.  It  might  be  well  before  the  injection  of  the 
nutrient  enema  to  give  a  preliminary  colon  irrigation  to 
thoroughly  cleanse  the  lower  bowel  and  render  it  more  absorbent. 


CHAPTER  VIII. 

DISEASES  OF  THE  NOSE,  THROAT  AND  LARYNX. 
ACUTE  RHINITIS. 

Synonyms. — Coryza,  acute  nasal  catarrh,  snuffles. 

Etiology. — The  most  frequent  cause  of  this  condition  is  a 
growth  of  adenoid  tissue  in  the  nasopharynx.  Its  occurrence 
in  infants  is  comparatively  frequent,  and  in  the  presence  of 
acute  symptoms  in  the  nose  the  nasopharynx  should  be  inves- 
tigated. Congenital  deformity  of  the  nose,  or  deformity  result- 
ing from  an  injury  may  mechanically  act  as  a  predisposing 
cause. 

Exposure  of  the  child,  being  uncovered  at  night,  with  a  wet 
napkin,  may  cause  trouble  because  of  the  extra  work  thrown 
upon  the  air  passages  from  interference  with  the  skin  by  chilling. 

Pathogenic  organisms  are  a  potent  factor,  as  a  dust-laden  air. 
A  child  should  never  be  kept  in  a  room  which  is  being  swept. 

Pathology. — The  entire  mucous  lining  of  the  nose  is  much 
congested  and  swollen,  due  to  an  increase  in  the  size  of  the 
blood  vessels  and  infiltration  of  lymphocytes  in  surrounding 
tissues.  A  watery  secretion  is  at  first  thrown  off,  followed  by 
a  mucopurulent  one. 

Symptoms. — There  is  at  first  sneezing  and  rubbing  of  the 
nose;  restlessness  and  difficulty  in  breathing  through  the  nose. 
This  is  specially  true  in  infants  when  nursing,  breathing  being 
much  interfered  with  because  of  the  swelling  of  the  nasal 
mucous  membrane.  Occasionally  there  is  a  slight  rise  of  tem- 
perature, rarely  more  than  2°  F.  There  may  be  a  swelling  of 
the  submaxillary  glands.  If  the  discharge  is  profuse  there  may 
be  an  excoriation  of  the  skin  of  the  upper  lip  with  a  forma- 
tion of  crusts  or  scabs  at  the  nares. 

Diagnosis. — The  possibility  of  a  nasal  diphtheria  developing 
primarily  should  be  borne  in  mind,  and  a  careful  inspection 

152 


DISEASES   OP    THE   NOSE,    THROAT   AND   LARYNX.  153 

of  the  nasal  nmcous  membrane  made  for  the  presence  of  a 
pseudomembrane.  The  nose  on  examination  will  be  found 
occluded,  the  red  and  swollen  turbinal  tissues  touching  the 
floor  and  septum. 

If  the  condition  does  not  respond  to  treatment  and  becomes 
chronic,  the  possibility  of  its  being  a  manifestation  of  congenital 
syphilis  must  be  borne  in  mind. 

Treatment. — Calomel,  gr.  i  to  a  nursling  in  one  dose,  or  in 
repeated  small  doses,  or  a  castor  oil  purge,  will  prove  beneficial. 
There  is  no  contraindication  to  air,  but  there  should  be  no 
draughts.  Unless  it  be  very  cold,  the  child  does  much  better 
if  out  of  doors  in  a  protected  perambulator. 

A  50  per  cent  boracic  acid  solution,  as  an  irrigation,  is  of 
benefit.  This  should  be  followed  by  a  weak  boracic  acid  and 
vaseline  ointment,  gr.  i  to  "^  i,  applied  to  the  nasal  mucous  mem- 
brane on  a  cotton  swab.  In  older  children  an  oily  spray  of 
benzoinated  albolene  is  of  benefit.  Adrenalin  solution,  1-5,000 
applied  to  the  mucous  membrane  by  a  cotton  swab  is  beneficial. 
A  J^ew  drops  of  a  2  to  4  per  cent  argyrol  solution  is  helpful  also. 

The  use  of  cold  spinal  douches  is  of  great  benefit  in  pre- 
venting attacks  in  children  predisposed  to  them.  An  effectual 
method  of  applying  cold  to  the  chest  and  back  is  by  wringing 
a  sponge  or  coarse  washcloth  out  of  cold  water  and  rubbing  the 
skin  back  and  front  as  far  as  the  waist  each  morning,  followed 
by  a  brisk  rub. 

CHRONIC  RHINITIS. 

This  form  is  rare  in  children  and  follows  the  acute  fre- 
quently or  may  appear  as  a  manifestation  of  rachitis,  adenoids, 
nasal  polypi,  which  are  very  rare  in  children,  or  any  general 
condition  of  impaired  nutrition.  A  nasal  discharge  from  one 
nostril  should  always  make  one  suspicious  of  a  foreign  body 
in  the  nose. 

The  removal  of  the  cause  of  the  chronic  form  is  usually  fol- 
lowed by  relief  unless  there  is  a  hypertrophy  of  the  turbinate 
bones.  The  treatment  is  essentially  that  of  the  acute  variety; 
antiseptic  sprays  and  douches.  Seller's  and  Dobell's  solutions 
are  of  great  benefit. 


154  THE   DISEASES   OF    CHILDREN. 

ATROPHIC  RHINITIS. 

Atrophic  rhinitis  is  found  in  children  with  comparative  fre- 
quency, oftener  in  females  than  males,  and  begins  more  fre- 
quently at  about  the  age  of  12,  though  it  may  begin  earlier.  It 
rarely  begins  after  adult  life  is  reached. 

There  is  a  chronic  nasal  catarrh,  often  involving  the  pharynx 
and  larynx. 

Etiology. — The  exact  cause  is  not  known.  Anemia,  unhy- 
gienic surroundings  are  causes.  One  of  the  latest  theories  is 
that  it  follows  accessory  sinus  disease,  as  it  is  frequently  asso- 
ciated with  sinus  disease. 

Symptoms. — There  is  a  thick  yellowish  discharge,  which  dries 
quickly,  forming  thick  crusts.  These  and  the  discharge  beneath 
have  a  very  disagreeable  odor,  this  being  known,  as  in  adults, 
as  ozena.  This  odor  is  characteristic  and  peculiar  to  this  condi- 
tion, the  patient  not  being,  as  a  rule,  cognizant  of  it  at  all.  The 
child  does  not  breathe  readily  through  the  nose  because  of  the 
crusts.  Epistaxis  is  common  from  dislodgement  of  the  crusts 
following  picking  of  the  nose.  The  facies  is  much  the  same 
as  found  in  uncomplicated  adenoids,  aprosexia,  and  they  fre- 
quently complicate  this  form  of  catarrh,  in  about  5  per  cent 
of  cases.  Hypertrophy  of  the  turbinates  is  also  present  in 
about  the  same  percentage  of  cases.  Otitis  media  is  a  compli- 
cation met  in  about  10  per  cent  of  cases. 

Prognosis. — This  is  bad,  as  far  as  a  cure  is  concerned.  Some 
cases  recover  spontaneously. 

Treatment. — Attention  to  all  abnormal  conditions  of  the  nasal 
mucous  membrane  as  soon  as  diagnosed  is  most  important  as  a 
prophylactic.  Active  treatment  in  the  form  of  cleansing  sprays 
may  be  ineffectual  because  of  the  tenacity  of  the  crusts.  Dobell's 
and  Seiler  's  solutions  or  the  following : 

Sodii  bicarb. 
Borax. 
Table  salt. 
Equal  parts. 
S. :  One  teaspoon  to  a  tablespoonful  in  a  quart  of  boiled  water,  one-half 
to  be  used  in  each  nostril. 

These  solutions  are  best  used  in  a  fountain  syringe. 


DISEASES   OP    THE   NOSE,    THROAT   AND    LARYNX.  155 

If  the  odor  is  bad  permanganate  of  potash,  2  grains  to  the 
pint  of  water,  can  be  used  in  the  same  way. 

If  the  patient  is  old  enough,  and  is  tractable,  office  treatment 
is  efficient.  Applications  can  be  made,  consisting  of  iodine, 
2  per  cent  in  glycerine,  or  ichthyol  or  nitrate  of  silver  solution, 
2  per  cent,  with  massage  of  turbinates.  Plenty  of  fresh  air, 
tonics,  iodide  of  iron,  etc.,  are  specially  indicated. 

EPISTAXIS. 

A  hemorrhage  from  the  nose. 

Etiology. — Trauma  is  the  most  frequent  cause,  though  it  may 
be  a  manifestation  of  a  general  condition,  as  in  typhoid  fever, 
scorbutus,  hemophilia.  Nosebleed  may  be  the  first  symptom 
of  adenoids,  being  due  to  the  intense  congestion  of  the  turbinals, 
which  is  secondary  to  the  adenoid  growth. 

Older  children  who  have  suffered  from  a  rhinitis  pick  the 
nose  to  remove  encrustations,  and  abrasion  of  the  mucous  mem- 
brane frequently  results,  causing  more  or  less  bleeding.  Young 
girls  who  have  a  very  heavy  suit  of  hair  are  prone  to  have  fre- 
quent hemorrhages  from  the  nose. 

Rarely  it  may  be  a  manifestation  of  puberty  as  a  vicarious 
menstruation. 

Symptoms. — Hemorrhage  from  one  or  both  alae  is  the  prin- 
cipal.  symptom,  or  if  it  is  at  all  severe  the  symptoms  of  acute 
anemia  will  result.  If  the  bleeding  is  from  the  posterior  nares 
but  little  blood  will  escape  from  the  anterior  nares,  but  will  be 
spit  up  or  swallowed.     Vomiting  always  follows  this. 

Treatment. — The  nares  should  be  cleansed  and  with  good 
illumination  they  should  be  closely  examined  for  bleeding  areas, 
which  can  frequently  be  found  upon  the  septum.  An  applica- 
tion of  chromic  or  trichloracetic  acid  or  20  per  cent  solution  of 
nitrate  of  silver  upon  a  cotton-tipped  applicator  to  the  bleeding 
point  will  usually  suffice  to  arrest  it.  In  the  milder  forms  tannic 
acid,  and  often  adrenalin  will  suffice.  The  galvanic  cautery  is 
most  satisfactory  if  patient  can  be  controlled.  It  may  very 
rarely  be  necessary  to  pack  the  nares  with  a  cotton  pledget. 

Lemon  juice  applied  to  the  mucous  membrane  is  an  efficient 
styptic  agent. 


156 


THE   DISEASES   OP    CHILDREN. 

NASAL  POLYPI. 


These  growths,  which  usually  arise  from  the  middle  turbinate 
bones,  are  infrequent  in  infants,  but  sometimes  found  in  older 
children.  They  usually  have  a  pedicle  much  smaller  than  the 
body  of  the  polyp. 

Not  infrequently  the  mucous  membrane  covering  the  lower 
and  anterior  border  of  the  septum  is  hypertrophied  and  causes 


LYMPHOIDTISSUE 
OUTSIDE 
TONSILLAR 
CAPSULE 

StJRFACE 

tPITHELIUM    MUCOUS 
GLANDS 
MUSCULAR 
FIBERS  or  CAPSULE 

CAPSULE 


TRABECULA 

BLOOD 
VESSEL 
MUSCULAR  FIBER  OF  CAPSULE 


MUSCULAR 
FIBERS  OF 
CAPSULE 


Fig.  40. — A.  Crypts,  very  irreguliir  and  uneven.  CIross-seetiun  of  luuuan  tonsil, 
age  11  years,  dissected  out  in  capsule.  XIO.  Moderately  hypertrophied  with 
greatly    dilated   crypts   filled   with   detritus.      (Courtesy    Dr.    Harry   A.    Barnes.) 

an  obstruction  to  the  nares  much  like  that  from  a  polyp.  These 
polypi  may  be  papillomatous  in  character,  cystic  or  fibrous. 

Symptoms. — No  symptoms  are  usually  present  until  the  polyp 
is  of  such  size  as  to  mechanically  interfere  with  the  breathing 
when  they  are  those  of  a  rhinitis.  There  is  a  discharge  from  .the 
nose  and  inability  to  breathe  with  freedom  through  the  affected 
side,  headache  and  restlessness  at  night. 

Treatment. — The  polyp  should  be  removed  early.  It  may  be 
accomplished  by  means  of  the  snare,  forceps  or  excision,  the 
snare  being  preferred. 

DISEASES  OF  THE  TONSILS. 

Too  much  emphasis  cannot  be  placed  on  the  importance  of  a 
consideration  of  the  tonsils  in  childhood.  They  bear  an  impor- 
tant relationship  to  many  of  the  severe  illnesses  of  that  age, 


DISEASES   OP    THE   NOSE,    THROAT   AND   LARYNX.  157 

as  they  are  the  port  of  entry  of  many  specific  organisms  to  the 
lymphatic  and  general  circulation. 

The  tonsils  are  situated  between  the  pillars  of  the  fauces, 
and  are  a  collection  or  masses  of  lymphoid  tissue,  which  have 
within  them  a  number  of  crypts.  These  crypts  are  lined  with 
squamous  epithelium. 

The  tonsillar  membrane  is  easily  infected  and  the  subsequent 
inflammation  results  in  great  swelling  of  the  tonsils,  and  in 
many  cases  a  rapid  exfoliation  of  the  epithelia  in  the  crypts, 
which  with  the  fibrin  and  serum  rapidly  fill  up  the  crypts,  the 
swollen  tonsil  being  dotted  with  yellowish-white  spots.  In  the 
catarrhal  variety  of  tonsillitis  the  crypts  are  empty,  the  exfoli- 
ated epithelia  being  thrown  off.  Occasionally  the  crypts  contain 
a  small  concretion  of  broken-down  cells  and  serum  in  a  hardened 
mass,  which  decomposes,  giving  to  the  breath  a  most  disagreeable 
odor. 

The  relationship  between  tonsillitis  and  rheumatism  has  been 
referred  to  elsewhere.  The  local  manifestation  of  this  general 
condition  should  always  be  borne  in  mind. 

TONSILLITIS. 

Tw^o  forms  of  tonsillitis  can  be  considered,  the  acute  catarrhal 
and  follicular. 

Acute  Catarrhal  Tonsillitis. 

Etiology. — This  variety  is  more  often  seen  as  a  manifestation 
of  rheumatism.  Exposure  to  cold,  wet  feet,  and  indiscretions 
in  diet  are  the  most  frequent  causes.  Children  who  are  fed 
sweets  indiscriminately  are  especially  prone  to  develop  tonsil- 
litis. Crowded  school  and  sleeping  rooms  with  improper  ventila- 
tion is  frequently  a  contributing  cause  to  this  condition. 

Symptoms. — The  first  symptom  may  be  a  chill  or  perhaps  an 
elevation  of  temperature.  The  child  will,  more  than  likely,  not 
complain  of  its  throat  at  all,  or  perhaps  only  when  it  swal- 
lows. It  may  have  pain  or  discomfort  in  its  joints,  manifested 
only  by  crying  when  moved  or  handled. 

Food  is  frequently  refused,  due  chiefly  perhaps  to  the  pain 
in  the  throat,  which  is  not  otherwise  complained  of. 


158  THE   DISEASES   OF    CHILDREN. 

The  temperature  is  always  elevated,  it  may  be  to  103°  F., 
which  lasts  for  two  or  three  days,  gradually  subsiding.  There 
are  remissions  but  it  does  not  reach  normal.  Because  of  the 
infrequency  of  complaint  in  regard  to  the  throat  from  both 
infants  and  children  no  examination  should  be  considered  com- 
plete without  a  thorough  inspection  of  the  throat  by  either  a 
good  direct  light  or  a  reflected  light  from  a  head  mirror. 

The  inflammatory  process  is  rarely  limited  to  the  tonsils,  as 
there  is  a  more  or -less  extensive  involvement  of  the  pharyngeal 
mucous  membrane. 

The  tonsils  will  be  found  enlarged,  very  red  and  granular 
in  appearance,  and  if  the  child  gags  when  the  tongue  is  de- 
pressed the  tonsils  may  approximate  in  the  center. 

The  bowels  are  usually  constipated  and  it  is  not  unusual  for 
vomiting  to  occur  at  the  onset. 

Prognosis. — This  is  good  in  an  uncomplicated  catarrhal  ton- 
sillitis, but  the  danger  is  always  great  of  an  infection  occurring 
of  the  tissue  behind  the  tonsil,  and  the  formation  of  a  localized 
abscess.  The  occurrence  of  frequent  attacks  of  catarrhal  tonsil- 
litis is  suggestive  of  a  rheumatic  diathesis. 

Treatment. — An  initial  dose  of  calomel  in  all  tonsillar  and 
pharyngeal  inflammations  is  a  positive  indication.  The  dose 
should  be  larger  than  is  ordinarily  given  children,  at  least  2 
grains  for  a  child  two  years  old.  This  should  be  followed  by  a 
dose  of  aromatic  cascara,  milk  of  magnesia  or  other  palatable 
laxative. 

One  of  the  salicylates  should  be  given,  preferably  aspirin,  in 
dose  of  3  grains  at  three-  or  four-hour  intervals  to  child  of  three 
years. 

Locally  an  astringent  application  should  be  made  to  the  ton- 
sils, as  Loeffler's  solution  or  tannic  acid: 

loeffler's  solution. 
IJ  Mentholi  10  gm. 

Toluene  q.  s.  ad  36  cc. 

Add. 

Creolin  2  cc. 

Liq.  ferri  chloridi  4  cc. 

Alcoholis         q.  s.  ad   100  cc. — M 


DISEASES   OP   THE   NOSE,    THROAT  AND   LARYNX.  159 

A  cold,  wet  compress  applied  to  the  throat  is  of  great  benefit. 
In  very  acute  inflammations  with  high  fever  these  may  be 
renewed  every  hour. 

The  control  of  the  diet  is  most  important  and  sweets  should 
be  eliminated  entirely  from  the  bill  of  fare. 

Follicular  Tonsillitis. 

Synonym. — Acute  lacunar  amygdalitis. 

Etiology. — The  streptococcus,  staphylococcus  and  pneumococ- 
cus  are  probably  the  most  frequent  offenders.  They  gain 
entrance  to  the  tonsillar  crypts  and  there  set  up  a  severe  inflam- 
mation. 

Exposure  to  cold  or  wet,  and  the  rheumatic  diathesis  are  pre- 
disposing causes. 

Age  is  a  factor.  It  is  decidedly  more  frequent  under  the  age 
of  15  than  over  that  age.  Infants  under  six  months  of  age  are 
infrequently  affected.  Previous  attacks  act  as  a  predisposing 
factor. 

Symptoms. — The  onset  is  sudden.  While  a  distinct  chill  is 
difficult  to  determine  in  a  child  it  may  evidence  itself  by  cold 
and  blue  extremities,  pallor  of  the  face  and  blanched  lips. 

In  older  children  the  aching  of  the  joints,  back  and  legs. is 
quite  severe,  but  the  only  manifestation  of  this  symptom  in  an 
infant  may  be,  as  in  the  catarrhal  variety,  crying  when  it  is 
picked  up. 

The  temperature  is  elevated  to  103°  F.  or  105°  F.,  with  re- 
missions of  1°  or  so,  and  lasts  from  three  to  four  days.  The 
pulse  is  correspondingly  rapid.  In  some  the  respirations  may 
be  faster  as  a  result  of  the  temperature  and  toxemia. 

There  is  anorexia,  often  vomiting  and  the  bowels  irregular. 
During  the  latter  stage  there  may  be  thin  and  green  stools  from 
the  infection  following  swallowing  the  mucus  from  the  throat. 
Inspection  of  the  throat  shows  enlarged  tonsils,  very  red,  and 
studded  with  white  spots.  These  spots  are  the  ends  of  accumu- 
lations of  broken-down  epithelium,  serum  and  fibrin  in  the 
crypts,  and  as  they  are  squeezed  out  of  the  tonsils  may  coalesce 
on  the  surface  of  the  tonsil  and  form  a  pseudomembrane. 

The  pharynx  is  deeply  congested  and  swollen,  and  the  uvula 


160 


THE   DISEASES   OF    CHILDREN. 


edematous  and  red  also.  This  condition  may  be  present  and 
no  complaint  of  the  throat  be  made,  which  emphasizes  the  im- 
portance of  a  careful  examination  of  the  throat  in  every  case  of 
illness  in  a  child.     Sometimes  it  is  quite  painful  to  swallow. 

The  lymph  nodes  at  the  angle  of  the  jaw  and  under  the  ramus 
may  be  enlarged.     The  tonsils  can  be  easily  palpated  externally. 


Fig.    41. — -Osteomyelitis    following    streptococcic    infection    from    tonsillitis. 
Dr.    C.    B.    Spalding.) 


(Courtesy 


The  duration  of  an  attack  is  usually  four  or  five  days,  the 
temperature  falls  by  lysis,  the  tonsils  are  clean  and  gradually  re- 
duced in  size,  and  the  aching  is  entirely  relieved. 

Complications. — Infection  of  the  middle  ear,  retropharyngeal 
and  retrotonsillar  abscess,  osteomyelitis  endocarditis  may  com- 
plicate the  convalescence. 

Prognosis. — In  uncomplicated  cases  this  is  good. 

Diagnosis  is  chiefly  to  be  made  from  diphtheria.  This  fre- 
quently cannot  be  made  without  a  careful  bacteriologic  examina- 
tion. In  suspicious  cases  a  culture  should  always  be  made. 
Again  a  case  may  begin  as  an  uncomplicated  follicular  tonsillitis 
and  develop  into  diphtheria.  The  pseudomembrane  in  follicular 
tonsillitis  can  be  removed  without  leaving  a  bleeding  surface  be- 
low as  occurs  in  diphtheria. 

Treatment. — Calomel  should  be  given  as  soon  as  the  diagnosis 
is  made,  followed  by  a  saline  if  possible.     A  portion  of  a  bottle 


DISEASES   OP    THE   NOSE,    THROAT   AND    LARYNX.  161 

of  citrate  of  magnesia  can  be  given  usually.     Castor  oil  is  also 
of  benefit. 

If  the  child  is  old  enough  to  gargle  a  50  per  cent  solution  of 
peroxide  of  hydrogen  is  of  great  service  in  softening  and  remov- 
ing the  exudate.  Any  mild  antiseptic  solution  can  be  used  as 
a  gargle,  Dobell's  and  Seller's  solutions  are  efficient. 

Locally  the  tonsils  should  be  touched  with  a  mop  saturated 
with  an  astringent  solution,  as  tannic  acid  or  Loeffler's  solution. 
The  application  of  powdered  aspirin  directly  to  the  tonsil 
has  been  suggested  as  an  excellent  remedy. 

Internally  aspirin  should  be  given,  as  in  catarrhal  tonsillitis, 
followed  during  convalescence  by  the  tincture  of  the  chloride 
of  iron. 

I^  Tinct.  ferri  chloridi        3i 
Glycerine  3iii 

Aquae  destillat.  q.  s.  ad  ^ii. — ^M. 
Sig.  One  teaspooiiful  every  tliree  hours,  diluted. 

Rest  in  bed  and  isolation  are  positive  indications  and  should 
be  insisted  upon. 

Cold  compresses,  or  the  opposite,  hot  a,pplications  may  give 
great  relief. 

Chronically  Enlarged  Tonsils  require  surgical  intervention. 
Whenever  several  distinct  attacks  of  tonsillitis  have  occurred 
in  a  child,  leaving  in  the  interim  much  enlarged  tonsils,  or  when 
associated  with  aural  complications  as  progressive  deafness, 
catarrhal  and  suppurative  otitis  media,  or  persistent  enlargement 
of  the  glands  of  the  neck,  they  should  be  removed,  as  they  are 
a  constant  menace  to  the  child  from  infections  of  many  kinds. 

Symptoms. — Adenoids  are  usually  associated  with  chronic- 
tonsillar  hypertrophy  and  the  symptoms  are  more  or  less  the 
same.  There  is  a  facial  expression  peculiar  to  this  condition; 
disturbance  of  the  speaking  voice;  mouth  breathing;  disturbed 
sleep ;  snoring ;  and  frequent  attacks  of  acute  tonsillitis. 

In  a  young  child,  the  tonsils  should  be  removed  under  a  gen- 
eral anesthetic,  gas,  ether  or  chloroform.  The  operation  is  not 
as  easily  done  under  a  general  anesthetic  as  without,  but  the 
inconvenience  to  the  operator  is  more  than  counterbalanced  by 
the  comfort  of  the  patient.     It  is  brutal  to  forcibly  hold  a  child 


162  THE   DISEASES   OF    CHILDREN. 

and  remove  first  one  tonsil  and  then  the  other,  and  the  shock 
to  the  nervous  system  is  one  which  is  recovered  from  only  after 
a  great  while.  I  appreciate  that  this  opinion  is  at  variance 
with  the  ideas  of  many  specialists,  yet  I  am  convinced  this  is  cor- 
rect. The  tonsils  should  not  be  removed  too  soon  after  an  acute 
attack  of  tonsillitis,  as  the  danger  of  postoperative  hemorrhage 
is  too  great.  There  have  been  a  number  of  deaths  from  hem- 
orrhage after  tonsillotomy,  and  this  danger  should  always  be 
borne  in  mind. 

Tonsillotomy. — The  instrument  is  chosen  with  the  aperture 
of  the  proper  size  to  allow  the  tonsil  to  easily  slip  through,  slight 
pressure  is  made  externally  and  being  assured  nothing  but  the 
tonsil  is  embraced  in  the  instrument,  pressure  and  traction  are 
made  by  the  thumb  and  fingers  and  the  instrument  with  tonsil 


Fig.   42. — Tonsillotome. 

impaled  upon  the  prongs,  is  removed.  The  same  or  a  fresh 
instrument  may  be  used  for  the  opposite  tonsil,  but  the  second 
should  not  be  removed  until  the  bleeding  has  been  stopped  by 
pressure  with  a  hemostat  holding  a  small  gauze  sponge. 

Tonsillectomy. — Complete  enucleation  of  the  tonsil,  has,  in  the 
hands  of  most  operators  completely  supplanted  the  old  method 
of  tonsillotomy.  The  instruments  needed  are  a  tongue  depressor, 
or  a  needle  threaded  with  silk  fifteen  inches  in  length  which  is 
put  through  the  end  of  the  tongue  at  the  frenum  for  the  purpose 
of  making  traction  and  doing  away  with  need  for  a  tongue  de- 
pressor; a  tonsil  knife  for  freeing  tonsil  from  faucial  pillars; 
volsellum  forceps,  and  two  snares,  armed  with  silver  wire.  The 
patient,  under  a  general  anesthetic,  lies  upon  its  back,  with  right 
shoulder  elevated  by  sand  bag  and  head  turned  to  operator  sit- 
ting on  its  left  side.  The  tonsil  is  grasped  by  the  volsellum,  the 
mucous  membrane  incised,  and  the  tonsil  freed  of  its  lateral  at- 


DISEASES   OP    THE   NOSE,    THROAT   AND    LARYNX.  163 

tacliments.  The  snare  is  then  slipped  over  it  and  the  entire 
tonsil  enucleated  with  its  capsule.  While  pressure  is  being 
used  with  forceps  and  sponge  to  allay  hemorrhage  more  anesthetic 
is  administered  for  the  removal  of  the  second  tonsil.  The  second 
or  upper  tonsil  is  treated  in  the  same  manner,  hemorrhage 
stopped,  and  the  adenoid  then  removed.  The  patient  is  then 
turned  over,  head  well  over  the  edge  of  the  table,  and  cold  cloths 
applied  to  throat  and  forehead.  A  whitish  deposit  forms  over 
the  base  of  the  tonsil  which  greatly  resembles  a  pseudo-mem- 
brane, and  without  knowing  what  had  been  done,  one  might  easily 
be  led  into  a  mistaken  diagnosis  of  diphtheria.  This  disappears 
in  four  or  five  days. 

UVULITIS. 

An  elongated  uvula  is  sometimes  seen  in  older  children,  rarely 
in  infants. 

Symptoms. — There  is  an  irritation  in  the  throat,  a  hacking 
cough,  especially  when  the  patient  is  recumbent,  and  a  constant 
desire  to  swallow.  There  may  be  pain  on  swallowing.  The 
cough  may  be  suggestive  of  bronchitis,  but  no  signs  are  found 
in  the  chest,  unless  there  is  an  associated  bronchitis. 

Treatment. — The  application  once  or  twice  daily  of  an  astring- 
ent solution  will  usually  suffice.     The  following  is  recommended : 


n 

Acidi  tannici 

Glycerini 

Listerine 

3ss 
3ii 
3" 

Aquae  dest. 

q.  s. 

ad.  5"i 

M 

.  et  ft.  sol. 

Si 

g.  Apply  on  cotton 

swab  to 

uvula, 

In  older  children  a  gargle  of  Dobell's  solution  is  beneficial. 
If  the  condition  is  chronic  and  does  not  respond  to  local  appli- 
cations, an  excision  of  the  tip  of  the  uvula  may  be  necessary. 
Care  should  be  taken  to  limit  the  excised  portion  to  the  tip  of 
the  mucous  membrane,  not  cutting  the  muscle,  in  which  event  the 
pain  following  is  very  severe. 

Cold  applied  by  eating  ice,  and  cold  cloths  externally  is  of 
great  benefit  in  relieving  the  pain  following  the  operation. 


164  THE   DISEASES   OF    CHILDREN. 

PERITONSILLAR  ABSCESS. 

Synonym. — Q  uinsy. 

Etiology. — An  infection  from  a  tonsillitis  or  diphtheria  is 
usually  the  cause.  This  affection  is  very  rare  at  the  extremes 
of  life. 

Symptoms. — Pain  in  the  throat,  inability  to  swallow  without 
its  being  greatly  exaggerated  and  a  peculiar  voice,  as  if  it  were 
full  of  hot  mush,  are  the  principal  symptoms.  Stiffness  of  the 
neck,  pain  on  opening  the  mouth,  and  pain  referred  to  the  ear. 
There  is  also  an  increased  flow  of  saliva,  which  is  swallowed 
with  difficulty.  An  examination  shows  a  very  edematous  area 
near  the  tonsil,  which  usually  is  verj^  glassy  in  appearance.  The 
uvula  is  pushed  to  one  side  by  the  accumulations  of  pus  from 
behind. 

Prognosis. — A  few  cases  have  been  known  to  rupture  during 
sleep,  pus  entering  the  larynx,  producing  death  by  strangulation. 
Edema  of  the  larynx  may  follow  also. 

Treatment. — The  accumulation  may  be  quite  tense  and  require 
but  a  very  superficial  incision  to  evacuate  the  pus.  The  posi- 
tion of  the  ascending  pharyngeal  artery  must  be  remembered  in 
making  the  incision.  In  others  the  pus  is  difficult  to  locate  as 
it  constantly  burrows  behind  the  fascia  but  finally  toward  the 
surface  and  may  rupture  spontaneously.  Belief  is  almost  imme- 
diate as  soon  as  the  abscess  is  drained. 

Hot  applications  and  hot  gargles  assist  materially  in  reducing 
pain  and  hastening  rupture. 

RETROPHARYNGEAL  ABSCESS. 

The  retropharyngeal  nodes  become  infected  by  bacteria  through 
the  medium  of  the  lymphatics,  in  tonsillitis,  measles  and  other 
septic  conditions.  It  may  be  due  to  vertebral  caries,  and  as  a 
complication   of   tuberculosis,    rickets   and   syphilis. 

It  occurs  comparatively  frequently  in  infancy  and  childhood, 
especially  during  the  first  year. 

Symptoms. — The  acute '  symptoms,  pain  and  obstruction  to 
swallowing,  may  begin  abruptly.  The  glands  at  the  angle  of  the 
jaw   are  swollen   and   tender.     The   usual   examination   of   the 


DISEASES   OF    THE   NOSE,    THROAT   AND   LARYNX.  165 

throat  may  reveal  the  cause  of  the  trouble  at  first  glance,  and 
the  finger  introduced  in  the  mouth  will  feel  the  doughy  tumor 
extending  beyond  the  reach  of  the  finger.  Hoarseness  is  pres- 
ent if  the  abscess  presses  down  upon  the  larynx. 

Treatment. — The  positive  indication  is  to  open  the  abscess  and 
evacuate  the  pus  through  an  opening  as  large  as  possible. 

I  have  seen  one  infant  of  four  months  in  which  the  first  exami- 
nation by  the  finger  caused  dyspnea,  necessitating  intubation. 

ADENOIDS. 

Pathology. — An  hypertrophy  of  the  lymphoid  tissue  or  the 
mucous  glandular  tissue  in  the  nasopharynx  or  vault  of  the 
pharynx  is  designated  as  an  adenoid  growth.  The  growth  may 
be  lobulated  and  attached  by  one  base,  or  there  may  be  more 
than  one  of  these  masses.  The  mass  when  removed  may  resem- 
ble a  bunch  of  grapes  in  its  conformation. 

Owing  to  the  passive  congestion  of  the  nasopharyngeal  mucous 
membrane  from  pressure  and  mechanical  irritation  of  the  growth 
there  is  a  constant  secretion  of  mucus,  escaping  through  the 
nares  and  into  the  throat. 

Bacterial  growth  in  the  nasopharynx  in  which  tthere  are 
adenoids  is  very  active,  the  pneumococci,  streptococci  and  staph- 
ylococci being  most  often  found. 

The  mucous  membrane  around  the  opening  into  the  Eu- 
stachian tube,  and  extending  up  the  tube,  is  congested  and 
swollen,  and  bacteria  are  present. 

The  frequency  of  adenoids  has  been  given  as  from  15  to  50 
per  cent  of  all  children. 

Etiology. — It  is  often  a  family  characteristic.  Rachitis,  bad 
hygienic  surroundings,  chronically  enlarged  faucial  tonsils, 
thumb  sucking,  indiscretions  of  diet,  especially  liberal  eating  of 
sweets,  are  among  the  causes  of  this  condition. 

Symptoms. — A  child  with  adenoids  usually  presents  a  train 
of  symptoms  which  are  fairly  characteristic.  It  is  more  than 
usually  susceptible  to  "colds,"  having  the  snuffles  and  a  con- 
stant nasal  discharge;  breathes  through  the  nioutli,  both  asleep 
and  awake,  but  especially  when  asleep  and  lying  upon  its  back; 
it  is  inattentive  from  deafness,  and  apathetic,  due  to  impoverished 


*166  THE   DISEASES  OF   CHILDREN. 

blood  from  respiratory  obstruction ;  complains  frequently  of  ear- 
ache. 

After  adenoids  have  existed  some  time  the  change  which 
takes  place  in  the  conformation  of  the  face  is  fairly  character- 
istic. Guye  has  designated  this  facies  as  aprosexia.  There  is  a 
peculiar  prominence  of  the  nasal  bones,  giving  a  tendency  to 
an  appearance  called  hatchet  face,  the  lips  are  partially  open 
to  permit  of  mouth-breathing,  as  it  is  impossible  for  a  free  ex- 
change of  air  to  take  place  through  the  nose. 

It  has  been  generally  believed  that  adenoids  were  peculiar 
to  children  beyond  the  age  of  two  years,  but  it  has  been  found 
by  a  number  of  observers  that  they  occur  in  early  infancy,  the 
earlier  they  occur  the  more  serious  the  after-etfects,  unless  early 
remedied.  There  is  a  greater  tendency  to  recurrence  of  the 
growth  after  removal  in  the  very  young. 

Owing  to  the  low  position  of  the  nasopharynx  in  infancy  and 
its  relatively  greater  length  from  before  backward,  and  the  small- 
ness  of  the  nose  and  its  cavities,  a  very  small  growth  causes 
greater  obstruction.  The  presence  of  adenoids  in  an  infant  in- 
terferes with  its  nasal  respiration  to  such  an  extent  that  sucking 
and  swallowing  are  much  interfered  with,  and  these  in- 
terferences with  nutrition,  and  insufficient  oxygen,  cause  a 
condition  of  malnutrition  which  is  oftentimes  very  serious.  All 
of  the  diseases  of  malnutrition,  especially  rickets,  are  apt  to  fol- 
low, deformities  of  the  chest,  the  so-called  pigeon  breast,  is 
frequently  seen.  It  is  often  necessary  to  differentiate  adenoids 
in  which  there  is  a  constant  "snuffles"  from  congenital 
syphilis.  Infants  so  affected  are  restless  at  night,  waking  fre- 
quently, and  this  interference  with  proper  rest  adds  greatly  to 
the  state  of  malnutrition.  The  following  application  may  be 
made  to  the  adenoid-bearing  area,  but  without  much  hope  of 
causing  absorption. 

IJ  Tiiict.  iodini  5s9 

Menthol  gr.  sa 

Bonzoinated   albolene      '^i. 
]\I.     Siff.     Five  dro|tR  in  aiitcritir  iiarcs  witli  cliilil   lyiiij];  on  l)ack. 

In  later  childhood  it  is  rare  to  find  a  case  presenting  adenoids 
that  does  not  also  show  considerable  enlargement  of  the  faucial 


DISEASES   OF   THE   NOSE,    THROAT   AND   LARYNX.  167 

tonsils,  and  it  is  a  fact  frequently  recognized  that  if  the  adenoids 
are  removed  and  the  faucial  tonsils  left  the  tendency  to  the  re- 
currence of  adenoids  is  very  great. 

Owing  to  the  tendency  to  rapid  propagation  of  pathogenic 
bacteria  in  the  nasopharynx  in  which  there  are  adenoids  the 
complication  of  infection  of  the  middle  ear  is  very  frequently 
observed.  The  nasopharynx  is  filled  by  the  growth  which  presses 
on  the  opening  of  the  Eustachian  tube ;  this  interferes  with  the 
air  in  the  middle  ear  and  deafness,  which  is  a  prominent  feature 
of  these  cases,  is  caused. 

Treatment. — There  is  but  one  treatment  for  adenoid  growth 
and  that  is  surgical.  A  number  of  observers  have  tried  the 
effect  of  local  application  of  absorbofacients  and  internal  admin- 
istration of  the  iodides  with  no  effect  whatever.  There  is  per- 
haps no  operation  that  in  itself  is  so  simple,  which  gives  rise  to 
such  excellent  and  prompt  results,  as  the  cleaning  out  of  the 
nasopharynx  of  an  adenoid  growth  .sufficient  in  size  to  give 
symptoms. 

In  infants  the  removal  can  frequently  be  accomplished  with- 
out the  use  of  instruments,  as  the  mass  of  tissue  is  so  soft  as  to 
make  it  possible  to  crush  it  and  remove  it  by  the  finger. 

In  older  children  it  is  my  opinion  that  the  operation  should 
never  be  done  without  a  general  anesthetic.  The  dangers  of 
the  anesthetic  are  greatly  outweighed  by  the  shock  to  the  nerv- 
ous system,  from  forcibly  holding  the  patient  and  brutally 
scraping  out  this  growth.  Cases  in  which  this  operation  is 
done  without  an  anesthetic  are  much  more  apt  to  have  the 
growth  recur  from  the  incompleteness  of  the  operation.  In  com- 
petent hands  the  best  anesthetic  is  chloroform.  I  make  this 
statement  in  spite  of  the  statistics  showing  the  comparative 
greater  safety  of  ether  over  chloroform.  I  have  given  chloro- 
fonn  for  this  operation  a  great  number  of  times  without  ever 
seeing  a  dangerous  symptom.  The  patient  should  be  recumbent 
upon  the  table  upon  which  the  operation  is  to  be  done,  and  the 
anestliesia  produced  should  be  only  to  the  primary  degree.  The 
mouth  gag  of  the  O'Dwyer  intubation  set  is  then  introduced, 
the  head  brought  well  to  the  edge  of  the  table  and  below  the 
level  of  the  body,  the  face  turned  to  one  side.     The  hair  is  pro- 


168  THE   DISEASES   OF    CHILDREN. 

tected  from  soiling  with  the  blood  by  a  rubber  bath  cap  which 
fits  snugly  over  the  forehead  and  under  the  occiput.  With  the 
patient  anesthetized  only  to  the  primary  stage  there  are  still  some 
reflexes  present,  and  the  tendency  to  swallow  blood  is  much  less 
than  if  they  are  completely  under  the  anesthetic.  There  are  few 
operations  in  which  the  loss  of  blood  is  as  great  for  the  amount 
of  work  done,  and  for  this  reason  it  is  always  well  for  members 
of  the  family  not  to  be  present  during  the  operation. 

The  child  lying  upon  its  back,  the  shoulders  are  pulled  to 
the  edge  of  the  table,  the  head  lowered,  with  the  face  turned 
to  the  side,  the  mouth  held  open  with  the  gag  and  the  finger 
as  a  guide,  the  growth  is  removed  by  means  of  the  curette,  which 
ordinarily  will  remove  the  entire  mass  in  one  or  two  scrapings. 
The  roof  of  the  pharynx  must  be  carefully  investigated  with  the 
finger  to  ascertain  if  entirely  clean.  The  danger  of  secondary 
hemorrhage  is  very  slight,  although  a  few  cases  have  been  re- 
corded of  this  nature.  After  cleansing  the  face  the  child  is  put 
to  bed  with  head  flat,  and  the  family  warned  of  the  possibility 
of  its  vomiting  blood  which  may  have  been  swallowed  during 
the  operation.  If  there  is  no  nausea  following,  in  the  course  of 
an  hour  or  so,  crushed  ice  may  be  given  the  patient  if  it  craves 
water,  and  later  ice  cream  or  cold  milk  when  nourishment  is 
necessary. 

As  a  rule  no  after  treatment  is  needed,  and  the  beneficial  ef- 
fects of  the  operation  while  generally  not  immediate  are  very 
soon  noticed  in  the  relief  of  all  previous  disagreeable  symptoms, 
the  first  usually  to  disappear  is  the  snuffles  or  symptoms  of  cold 
in  the  head.  There  is  a  change  in  the  voice  and  the  child  is  less 
restless  at  night,  and  the  mouth-breathing  soon  disappears.  In 
those  who  have  been  in  the  habit  of  breathing  through  the  mouth 
for  some  time  it  may  be  necessary  to  frequently  remind  them 
of  the  necessity  of  keeping  the  mouth  closed. 

DISEASES  OF  THE  LARYNX. 
Acute  Catarrhal  Laryngitis. 
Synonyms. — Croup.    Spasmodic  croup.     Catarrhal  croup. 
Etiology. — Exposure  to  cold  is  the  most  frequent  predisposing 
cause.     Any  of  the  bacteria  found  in  the  throat  in  tonsillitis 


DISEASES   OF    THE   NOSE,    THROAT   AND    LARYNX,  169 

may  be  the  active  cause  of  the  inflammation.  The  bacillus  of 
diphtheria  is  not  present,  as  a  membrane  would  be  the  result  of 
such  invasion  and  a  true  croup  caused. 

Symptoms. — The  child  is  usually  put  to  bed  in  apparently  a 
normal  condition.  It  may  perhaps  have  had  a  slight  hoarseness 
or  a  hacking  cough  during  the  day  or  several  days  previously, 
or  a  slight  coryza  without  the  cough.  After  having  been  asleep 
for  some  time  it  will  cough,  the  sound  produced  being  harsh  and 
brassy  which  is  the  characteristic  croupy  cough,  and  which 
strikes  terror  to  every  mother's  heart.  This  cough  may  awaken 
the  child,  and  there  is  a  rasping  character  to  the  inspiration 
and  the  cry,  which  may  be  heard  and  recognized  some  distance 
away.  If  very  severe  the  child  may  show  considerable  pallor 
and  exhibit  other  symptoms  of  dyspnea,  clutching  at  the  throat 
with  a  recession  of  the  supraclavicular  and  infraclavicular  spaces 
with  each  inspiration.  The  skin  is  clammy  as  a  rule,  though 
there  may  be  a  dusky  flush  to  the  cheeks  if  there  is  any  fever, 
which  is  usually  below  103°  F. 

The  spasmodic  stage  may  last  some  hours,  but  it  is  usually 
shorter  in  duration,  and  by  morning  the  child  is  asleep  and 
breathing  quietly.  During  the  day  it  will  play  around  with- 
out, as  a  rule,  much  hoarseness  evidencing  itself.  The  croupy 
cough,  however,  usually  recurs  the  following  night  or  for  several 
nights,  however,  less  severe  as  a  rule. 

Diagnosis. — This  must  be  made  from  laryngeal  diphtheria.  In 
this  the  symptoms  grow  gradually  worse,  instead  of  disappearing 
during  the  day,  to  recur  at  night,  as  in  catarrhal  laryngitis. 
Some  membrane  is  usually  present  in  other  parts  of  the  throat, 
in  diphtheria. 

In  laryngismus  stridulus,  the  pronounced  croupy  cough  is  not 
so  prominent,  the  dyspnea  and  stridor  being  most  marked. 
There  is  no  fever  in  laryngismus  and  the  duration  is  shorter. 
Laryngismus  is  a  prominent  symptom  of  rickets,  and  does  not 
occur  in  other  conditions. 

Prognosis. — This  is  good  when  uncomplicated. 

Treatment. — If  the  stridor  is  great,  the  best  results  can  be 
had  by  giving  a  preliminary  dose  of  syrup  of  ipecac  of  20  to 
60  drops,  for  its  full  effect  upon  the  stomach.     After  vomit- 


170 


THE   DISEASES   OP    CHILDREN. 


ing,  the  whole  aspect  of  the  case  is  usually  changed,  as  by  doing 
so  the  mucus  in  the  trachea  and  larynx  is  dislodged  and  this 
mechanical  obstruction  removed.  This  dose  can  be  repeated  at 
half  hour  or  hourly  intervals  as  needed  to  produce  emesis.  Con- 
tinuing the  effect  of  relaxation, 
good  results  are  had  from  anti- 
mony and  ipecac,  1/100  grain 
each,  every  hour. 

Excellent  results  are  had  from 
allowing  the  child  to  breathe 
steam,  and  the  ''croup  kettle" 
which  generates  steam  by  the  bed- 
side, should  be  used.  One  tea- 
spoonful  of  the  tincture  of  benzoin 
to  a  pint  of  water  vaporized  is  of 
great  service.  When  the  child  is 
asleep  a  sheet  tent  should  be 
erected  over  the  crib  so  as  to  con- 
fine the  steam.  The  kettle,  as  long 
as  the  lamp  is  lighted,  should  be  closely .  watched  and  not  left 
unattended  at  all. 

For  severe  cases,  with  great  recession  of  the  spaces,  and  ap- 
parent danger  of  complete  obstruction,  intubation,  as  for  diph- 
theritic laryngitis,  should  be  performed. 

The  application  of  a  wet,  cold  compress  is  of  service  in  reduc- 
ing the  swelling  of  the  vocal  cords. 


Croup   Kcttit 


Congenital  Laryngeal  Stridor. 

This  is  an  obscure  condition  and  no  cause  has  been  satisfactor- 
ily named,  in  the  absence  of  pathological  conditions  which  by 
pressure  would  cause  obstruction  to  the  larynx.  Enlarged  thy- 
mus gland  has  been  found,  causing  pressure,  the  peculiar  crow- 
ing sound  being  produced. 

Symptoms. — ^Within  a  few  days  after  birth  the  child  is  no- 
ticed to  make  a  peculiar  high-pitched  crowing  inspiratory  sound ; 
louder  when  disturbed  or  crying,  and  then  associated  with  re- 
cession of  the  supra  and  infra  clavicular  spaces.     The  proper 


DISEASES   OP   THE   NOSE,    THROAT   AND    LARYNX.  171 

oxygenation  of  the  blood  appears  to  occur  as  no  cyanosis  is  pres- 
ent. 

Course. — The  condition  tends  to  a  spontaneous  cure,  a  decided 
improvement  usually  occurring  before  the  end  of  the  first  year. 
No  treatment  is  of  avail. 


CHAPTER  IX. 

DISEASES  OF  THE  EAR. 

Deafness  in  children  is  much  more  frequently  present  than 
is  ordinarily  thought,  and  in  school  children  may  prove  a  serious 
handicap  to  their  progress.  In  this  period  any  defect  in  hear- 
ing will  interfere  with  the  development  of  speech,  and  inatten- 
tion and  slow  mental  development  is  the  result.  Inattention 
in  an  otherwise  normal  child  should  cause  an  examination  to 
be  made  of  the  child. 

Adenoids  is  perhaps  the  most  frequent  cause  of  deafness ;  next 
being  nasopharyngeal  catarrh,  with  an  occlusion  of  the 
Eustachian  tube  and  the  extension  of  the  inflammatory  process 
to  the  middle  ear.  These  children  if  watched  at  play  will  be 
seen  to  have  less  endurance,  and  this  is  exaggerated  in  damp, 
humid  weather. 

Every  child  should  be  examined  at  school  for  acuteness  of  its 
hearing,  and  in  the  presence  of  its  teacher.  If  the  hearing  is 
found  defective,  an  otologist  should  be  consulted  in  order  to 
locate  the  cause  of  the  defect. 

This  is  one  of  the  many  advantages  which  can  be  gained  from 
medical  inspection  of  schools. 

EXTERNAL  AUDITORY  CANAL. 

Furunculosis. — The  most  frequent  condition  affecting  the  ca- 
nal is  a  furunculosis  of  the  skin  inside  the  nieatus.  This  is  not 
often  seen  in  young  children  but  comparatively  often  in  those 
approaching  puberty. 

Etiology. — The  practice  of  children  putting  foreign  bodies  in 
their  ears  is  a  potent  factor.  This  causes  an  abrasion  of  the 
skin  and  an  infection,  usually  by  the  staphylococcus,  which  in 
one  form  or  another  are  normally  found  in  the  hair  follicles 

172  ' 


DISEASES   OF   THE  EAR.  173 

of  the  canal.  In  older  children  the  employment  of  pin  heads 
and  sharp  instruments  to  give  relief  from  itching  or  to  clean 
out  the  normal  secretion  of  wax  results  in  an  infection. 

Pathology. — There  may  be  a  diffuse  inflammation  of  the  skin 
of  the  entire  canal,  or  one  or  more  discreet  furuncles.  The 
swelling  may  be  diffuse  enough  to  make  an  examination  of  the 
drum  impossible. 

Symptoms. — Perhaps  more  pain  is  caused  by  inflammation  lo- 
cated here  than  at  any  other  part  of  the  body,  owing  to  the  tense- 
ness of  the  tissues  of  the  canal.  Pressure  pain  develops  early, 
and  if  the  furuncle  is  located  near  to  the  meatus  movement  of 
or  touching  the  external  ear  causes  pain.  There  may  be  a  slight 
rise  of  temperature,  to  101°  F.,  occasionally,  loss  of  sleep  and 
of  appetite,  with  general  depression  and  irritability.  Unless  re- 
lieved by  incision,  the  furuncle  generally  ruptures  spontaneously 
during  the  first  week  and  immediate  relief  is  afforded  by  the 
escape  of  pus  and  blood.  Unfortunately  one  boil  may  be  followed 
by  another,  as  it  is  next  to  impossible  to  keep  the  parts  sterile 
after  discharge  of  pus  from  the  first  one  takes  place. 

The  location  of  the  boil  can  be  made  out  by  the  use  of  a 
cotton-protected  probe.  A  speculum  cannot  always  be  used  on 
account  of  the  tenderness.  ^Mastoiditis  must  be  differentiated 
from,  which ,  is  chiefly  done  by  pressure  on  the  mastoid  bone, 
eliciting  tenderness  in  the  latter  only. 

Treatment. — Abortion  of  the  boil  is  possible.  This  can  some- 
times be  effected  by  leeches  applied  just  external  to  the  auditory 
canal,  care  being  taken  to  plug  the  canal  with  cotton  to  prevent 
their  migration  into  it.  Locally,  cotton,  saturated  with  a  50 
per  cent  ichthyol  and  glycerine  solution  may  be  of  benefit.  The 
continuous  application  of  heat  by  irrigation  with  a  fountain 
syringe  is  of  great  benefit.  Efforts  at  aborting  the  boil  being 
ineffectual,  an  incision  is  absolutely  necessary,  and  this  should 
be  made  with  a  special  furuncle  knife  with  a  triangular  or  a 
half-curved  blade,  and  the  incision  made  through  the  furuncle 
and  the  tissue  on  either  side  of  it,  thus  draining  the  collection 
of  pus  and  reducing  the  congestion  also. 

This  operation  is  so  painful  that  the  administration  of  a  gen- 
eral anesthetic  is  urged.     Laughing  gas  is  most  efficient,  having 


174  THE   DISEASES   OP    CHILDREN. 

the  advantage  of  lack  of  after-effects,  nausea,  etc.  If  this  is  not 
available,  chloroform  to  the  primary  stage  should  be  used. 

If  these  furuncles  are  recurrent  the  injection  of  the  bacterial 
vaccines  is  recommended. 

Local  antiseptics  and  cleansing  should  constitute  the  after 
treatment,  probably  using  irrigations  two  or  three  times  a  day. 

IMPACTED  WAX. 

The  natural  secretion  of  cerumen  may  be  increased  in  amount 
and  collect  in  the  canal,  and  when  mixed  with  the  epithelium 
of  the  canal  may  obstruct  the  entire  meatus.  The  mass  may  be 
pushed  inward  and  press  against  the  drum.  This  frequently 
causes  symptoms  such  as  tinnitus,  gradual  deafness,  a  sense  of 
fulness  in  the  ear,  or  more  or  less  pain,  dizziness  and  perhaps 
vomiting.  An  examination  of  the  ear  with  a  good,  reflected  light 
is  sufficient  to  make  the  diagnosis.  At  first  it  may  resemble  a 
foreign  body  in  the  canal. 

Treatment. — The  wax  may  be  removed  with  a  curette  if  close 
to  the  orifice,  but  frequently  will  have  to  be  softened  by  repeated 
syringing  with  warm  water  in  a  piston  syringe.  The  force 
obtained  from  a  fountain  syringe  will  not  disintegrate  the  mass 
as  a  rule.  The  fluid  used  should  either  be  plain  sterile  water, 
normal  salt  solution  or  saturated  boracic  acid  solution. 

If  syringing  does  not  succeed  in  disintegrating  the  mass,  a 
solution  can  be  used  as  follows  for  instilling  into  the  ear  three 
times  a  day,  until  the  wax  has  softened : 


n 

Acid   carbolic 

Tll.i 

Acid  boracic 

gr.  XX 

.Sodium  biborat. 

gr.  X 

Glycerine 

5SS 

Aquae  dest. 

5SS 

A  dry  dressing  of  powder  should  be  blown  in  the  ear  after 
the  wax  has  been  removed. 

THE  MIDDLE  EAR. 

The  student  and  practitioner  should  familiarize  himself  with 
the  appearance  of  the  normal  drum  membrane,  should  be  able 


DISEASES   OP   THE   EAR.  175 

to  locate  the  landmarks,  as  follows:  The  short  process  of  the 
hammer;  the  handle  of  the  hammer  or  malleus;  the  triangular 
light  spot.  The  normal  color  is  a  pearl-gray,  and  abnormal  con- 
ditions evidence  themselves  chiefly  in  a  change  of  color  of  the 
drum. 

Inflammations  of  the  middle  ear  are  either  suppurative,  which 
may  or  may  not  have  been  the  result  directly  of  an  extension 
upward  of  an  inflammation  of  the  Eustachian  tube. 

ACUTE  TUBOTYMPANIC  CATARRH. 

Etiology. — ^Whether  the  normal  middle  ear  contains  bacteria 
is  a  debatable  question,  equally  prominent  authorities  holding 
opposite  views.  Bacteria  may  gain  entrance  to  the  tympanic 
cavity  through  an  opening  in  the  drum,  the  result  of  trauma,  or 
through  the  Eustachian  tube.  They  may  obtain  entrance  also 
via  the  blood  and  lymphatics. 

The  most  frequently  observed  bacteria  are  the  streptococcus 
and  staphylococcus;  though  the  following  may  be  found,  the 
pneumococcus,  the  bacillus  pyocyaneus,  Klebs-Loeffler  bacillus, 
the  meningococcus  intracellularis,  influenza  bacillus  and  the  colon 
bacillus. 

Nasopharyngeal  adenoids  are  one  of  the  most  frequent  causes 
of  catarrhal  inflammation  of  the  mucous  membrane  of  the  middle 
ear.  They  are  the  most  frequent  cause  of  the  so-called  colds 
and  acute  coryza  which  so  frequently  precede  an  acute  tym- 
panic catarrh  without  suppuration. 

Pathology. — Inflammation  may  rarely  be  limited  to  the  Eu- 
stachian tube,  but  usually  extends  to  the  cavity  as  well.  As  a 
result  of  the  inflammation,  swelling  and  occlusion  of  the  Eu- 
stachian tube  there  is  a  slight  accumulation  of  serum  and  an 
absorption  of  the  air  in  the  middle  ear,  and  a  coincident  inward 
depression  of  the  drum  membrane. 

Symptoms. — The  first  symptom  which  is  present  is  usually  an 
impairment  of  hearing,  followed  by  a  sense  of  fulness  on  the 
affected  side,  ringing  in  the  ear,  perhaps  dizziness.  When  the 
catarrhal  inflammation  extends  to  the  middle  ear  there  is  a 
swelling  of  the  mucous  membrane  and  more  or  less  pain. 

In  the  early  stages,  when  most  of  the  involvement  is  in  the 


176  THE   DISEASES   OF    CHILDREN. 

Eustachian  tube,  the  drum  membrane  is  retracted,  but  subse- 
quent examinations  may  show  a  collection  of  fluid  in  the  cavity. 

Prognosis. — Early  recognition  and  prompt  treatment  make 
the  prognosis  favorable.  The  restoration  of  a  diseased  condi- 
tion of  the  nasopharynx  to  normal  greatly  influences  the  prog- 
nosis and  limits  the  possibilities  of  a  return  of  the  condition. 

Treatment. — When  only  the  tube  is  involved,  with  more  or 
less  occlusion,  it  must  be  opened,  either  by  the  Eustachian  cathe- 
ter or  by  the  Politzer  bag.  The  catheter  is  entirely  impractical 
in  children,  and  inflation  of  the  drum  by  the  Politzer  bag  yields 
the  best  results. 

First  cleanse  the  nose  and  pharynx  with  an  antiseptic  spray 
(Dobell's  solution  or  Seiler's  solution),  followed  by  a  nebulizer. 

Several  methods  of  Politzeration  are  advised.  The  child  is 
seated,  the  tip  of  the  bag  is  placed  well  in  the  nostril  of  the 
affected  side  and  held,  the  opposite  nostril  being  compressed. 
The  child  is  then  told  to  count  one,  two,  three,  and  as  the  last 
word  is  said  the  bag  is  squeezed,  which  usually  effectually  in- 
flates the  affected  side.  The  child  may  be  told  to  fill  the  lungs 
with  air  and  forcibly  to  blow  it  out  through  puckered  lips,  the 
bag  is  then  squeezed  and  the  drum  inflated.     In  older  children 


Fig.  44. — For  paracentesis  of  the  drum. 


the  inflation  can  be  accomplished  as  a  swallow  of  water  is  taken, 
but  in  younger  children  this  is  impractical  because  of  the  danger 
of  choking. 

The  Politzeration  should  be  done  every  day  for  three  or  four 
days,  and  then  every  other  day,  and  finally  once  a  week  for 
several  weeks. 

In  the  presence  of  a  collection  of  fluid  in  the  cavity  a  para- 
centesis or  incision  of  the  drum  should  be  done. 

For  this  operation  a  general  anesthetic  should  always  be  given 
as  the  pain  is  very  acute.     The  necessity  for  a  paracentesis  rarely 


DISEASES   OF   THE   EAR.  177 

exists  until  the  patient  has  already  suffered  acutely  for  a  num- 
ber of  hours,  probably  having  lost  much  sleep;  hence  the  inflic- 
tion of  additional  acute  pain  should  not  be  allowed.  Local 
anesthetics  are  not  of  much  avail.  The  following  can  be  used 
with  some  benefit: 

IJ  Cocaine  muriat       gr.  x 
Ac.  boracic  saturated  sol. 
Alcohol  aa  5i 

M.     Politzeration  should  be  performed  after  paracentesis. 

ACUTE  CATARRHAL  OTITIS  MEDIA. 

Pathology. — The  mucous  membrane  lining  the  middle  ear  is 
acutely  inflamed  and  swollen,  and  an  exudate  usually  occurs, 
being  either  serous  or  mucous,  bathing  the  mucous  membrane. 
There  may  be  an  accumulation  sufficient  to  fill  the  cavity. 

Etiology. — While  this  condition  may  occur  as  a  primary  af- 
fection it  is  usually  an  extension  of  the  process  from  the  naso- 
pharynx, any  of  the  bacteria  named  in  the  previous  section  being 
found  in  the  tympanic  cavity.  Bacteria  in  the  nasopharynx 
may  be  forced  in  the  cavity  through  the  tube  by  nasal  douches 
or  sprays,  gargling  or  coughing  when  swallowing. 

As  a  complication  in  the  acute  exanthemata,  this  form  of  otitis 
is  most  frequent. 

Symptoms. — Any  severe  pain  in  the  ear  is  always  suggestive 
of  this  form  of  trouble.  It  is  at  first  a  dull,  deep-seated  ache, 
gradually  increasing  in  severity  until  it  becomes  sharp  and  lan- 
cinating; sleep  is  impossible,  and  older  children  walk  the  floor 
holding  the  affected  side.  Remissions  in  the  severe  pain  are 
hardly  long  enough  to  allow  the  child  to  fall  asleep,  crying  out 
with  each  exacerbation.  Younger  children  usually  pull  at  the 
affected  side. 

If  old  enough  to  tell,  the  watch  test  evidences  deafness  to  a 
greater  or  less  degree,  according  to  the  severity  of  the  inflamma- 
tion and  amount  of  effusion.  Some  complain  of  the  ringing  in 
the  ears,  in  others  this  is  less  noticeable. 

Pain  is  severe  until  the  fluid  in  the  ear  escapes,  either  through 
a  spontaneous  rupture  in  the  drum  or  a  paracentesis  of  the  drum 


178  THE   DISEASES   OF    CHILDREN. 

is  performed,  when  the  feeling  of  relief  is  immediate  and  the 
child  falls  asleep. 

iln  children  there  is  usually  a  rise  of  temperature,  from  1°  to 
3°  F.,  though  there  may  be  no  rise  at  all.  As  a  complication 
of  the  exanthemata  there  is  nearly  always  an  elevation.  A  child 
n^ay  waken  in  the  night  with  an  earache,  having  previously  suf- 
fered from  an  acute  coryza,  perhaps  have  a  slight  remission  in 
tie  pain  during  the  day,  with  a  recurrence  of  it  at  night,  per- 
manent relief  being  had  only  after  spontaneous  rupture  of  the 
drum  and  escape  of  the  mucus  or  serum,  and  all  ef  this  without 
elevation  of  temperature.  This  rupture  may  occur  in  12  hours 
after  the  onset  of  the  pain,  but  may  be  delayed  for  three  days. 

The  drum  membrane,  if  examined  before  rupture,  is  found 
to  have  changed  to  a  deep  or  cherry-red  color,  the  landmarks 
have  disappeared,  and  if  the  exudation  has  occurred  in  the  cavity 
the  drum  bulges  outward  in  some  portion,  usually  it  being  great- 
est in  the  upper,  posterior  portion..  If  the  drum  has  previously 
ruptured  the  canal  is  filled  with  exudate,  and  a  free  view  of  the 
drum  cannot  be  had  without  a  previous  cleansing  with  a  cotton- 
protected  swab. 

Untreated  or  neglected  cases  of  the  catarrhal  variety  of  otitis 
usually  develop  into  the  suppurative  form,  especially  after  a 
perforation  of  the  drum  has  occurred.  The  opening  in  the  drum 
from  a  perforation  is  usually  found  in  the  inferior  quadrant,  to 
the  right  or  left. 

Prognosis. — The  majority  of  these  cases  completely  recover. 
The  condition  of  the  nasopharynx  influences  the  prognosis.  Per- 
sistence of  a  nasopharyngeal  catarrh,  adenoids  and  anemia,  tend 
to  the  likelihood  of  recurrence  of  this  trouble. 

Treatment. — If  seen  early,  before  there  has  been  a  perfora- 
tion of  the  drum,  an  anodyne  is  necessary,  opium  in  some  form 
being  most  efficacious.  The  camphorated  tincture  or  the  deodor- 
ized tincture  may  be  used. 

The  tampon  in  the  canal,  suggested  by  Barnhill,  is  of  service 
also.  A  cone  of  cotton  is  twisted  on  the  end  of  an  applicator, 
saturating  the  end  of  the  cotton  with  a  phenol  (10  per  cent)  and 
glycerine  (90  per  cent)  solution,  and  holding  it  over  a  flame 
until  as  hot  as  can  be  stood  on  the  back  of  the  hand,  and  before 


DISEASES   OF   THE   EAR.  179 

it  has  had  time  enough  to  cool  it  is  removed  from  the  applicator 
and  carried  back  against  the  drum  membrane  with  the  end  pro- 
jecting from  the  meatus. 

I  have  found  excellent  results  follow  the  use  of  an  irrigation 
of  the  ear  with  a  fountain  syringe,  using  water  as  hot  as  could 
be  borne  and  holding  the  syringe  not  more  than  12  inches  above 
the  head,  thus  doing  away  with  the  pressure  against  the  drum. 
The  child  should  be  persuaded  to  put  his  hand  in  the  water  for 
a  moment  to  become  familiar  with  its  temperature  before  it  is 
used  in  the  ear. 

Usually  before  the  physician  has  been  called  the  mother  has 
dropped  into  the  ear  some  warm  sweet  oil  and  laudanum  which, 
as  long  as  it  retains  its  heat,  is  effectual,  but  little  absorption  of 
the  laudanum  occurring. 

Paracentesis  of  the  drum  should  be  performed  as  soon  as  a 
bulging  drum  has  been  found.  This  should  be  done  under  strict 
antiseptic  precautions  and  in  the  subsequent  treatment  being 
most  careful  to  prevent  infection.  Rest  in  bed,  if  fever  is  pres- 
ent; indoors,  if  the  child  is  up. 

An  occasional  dose  of  calomel,  1  grain  at  a  dose  at  bedtime, 
followed  by  a  saline  the  next  morning ;  syringing  the  discharging 
ear  frequently;  at  first,  every  two  or  three  hours,  daily  after 
this;  drying  of  the  canal  by  cotton  swabs  and  insufflation  of 
canal  with  boracic  acid  powder  constitute  the  treatment  which 
generally  yields  the  best  results. 

A  sudden  cessation  of  the  discharge,  an  increase  in  or  return 
of  pain,  rise  in  temperature,  usually  indicates  a  too  early  closure 
of  the  drum, 

ACUTE  SUPPURATIVE  OTITIS  MEDIA. 

This  form  may  follow  the  catarrhal  otitis  or  originate  as  the 
suppurative  form.  A  large  percentage  of  cases  of  deafness  are 
due  to  this  variety  of  inflammation,  and  chronic  otitis  is  a  fre- 
quent ending. 

Etiology, — One  of  the  most  frequent  causes  is  bacterial  inva- 
sion of  the  tympanic  cavity  as  a  complication  of  influenza.  Large 
numbers  of  acute-discharging  ears  are  seen  every  winter  in  which 
influenza  is  epidemic. 


DISEASES   OF   THE  EAR.  181 

The  exanthemata,  especially  scarlatina  and  diphtheria,  are 
frequently  complicated  by  suppurating  middle  ears.  In  the 
former  disease  infection  of  the  ear  most  frequently  follows  the 
membranous  form  of  angina.  The  streptococci  are  most  fre- 
quently found  as  the  infecting  organism. 

As  in  the  other  varieties  of  middle  ear  involvement,  the  pres- 
ence of  adenoids  is  an  exciting  factor  of  middle-ear  suppuration. 

Symptoms. — No  other  condition  of  the  ear  presents  such  a 
variety  of  symptoms  as  this.  Some  may  be  present  with  severe 
constitutional  and  local  symptoms,  as  a  temperature  ranging 
from  normal  to  103°  or  104°  F.,  severe  prostration,  deafness  and 
agonizing  pain  in  the  ear.  In  others  one  of  the  first  symptoms 
will  be  the  discharge  from  the  ear  following,  perhaps,  a  sense  of 
discomfort  or  fulness  in  the  affected  side. 

It  is  usual,  however,  for  the  trouble  to  be  ushered  in  with  se- 
vere pain,  deafness,  tinnitus,  perhaps  vertigo  or  dizziness. 

The  accompanying  chart  is  of  a  patient  three  years  of  age 
who  presented  but  few  symptoms  before  the  discharge  began, 
and  practically  none  afterward,  except  the  temperature,  loss  of 
appetite  and  some  loss  in  weight.  The  discharge  was  profuse, 
and  when  the  opening  in  the  drum  became  slightly  closed,  caus- 
ing retention  of  secretions,  all  of  the  symptoms  were  aggravated. 

When  occurring  as  a  complication  in  the  exanthemata  there 
is  usually  a  rise  in  the  temperature,  especially  if  the  suppura- 
tion occurs  late  in  the  course  of  the  disease,  as  may  be  the  case. 

Usually  with  the  rupture  of  the  drum  the  pain  subsides  imme- 
diately, and  the  child  is  free  from  pain  unless  the  opening 
l)ecomes  blocked  with  discharge,  when  pain  is  again  severe. 
Where  the  child  has  been  previously  restless  and  crying,  as  soon 
as  the  rupture  takes  place  it  falls  into  a  peaceful  sleep.  It  is 
astonishing  to  see  the  amount  of  discharge  which  may  come  from 
the  middle  ear.  It  is  usually  thick  and  yellow,  caking  in  flakes 
upon  the  ear  and  beneath  when  it  is  profuse  enough  to  run  over. 

It  is  impossible  to  state  the  character  of  the  secretion  in  the 
middle  ear  by  the  looks  of  the  drum  rnembrane,  though  in  the 
suppurative  form  there  is  apt  to  be  a  larger  amount,  hence  more 
bulging.     The  membrane  is  reddened,  more  or  less  uniformly, 


182  THE   DISEASES   OF    CHILDREN. 

except  at  the  site  of  the  rupture,  which  may  be  imminent,  this 
showing  signs  of  necrosis  by  change  in  color. 

The  opening  in  the  drum  as  a  result  of  a  spontaneous  rupture 
may  vary  from  a  slit  to  a  practical  washing  away  of  the  entire 
drum. 

The  tendency  in  the  former  variety  of  opening  is  to  too  readily 
heal,  closing  before  the  discharge  has  ceased. 

Prognosis. — The  earlier  this  condition  is  recognized  and 
properly  treated  the  better  the  chances  of  recovery  with  normal 
hearing.  Continuance  of  fever  and  other  symptoms  after  dis- 
charge has  begun  indicates  an  involvement  of  deeper  structures 
as  the  mastoid  and  the  brain. 

Untreated  cases  develop  into  a  chronic  condition  with  con- 
tinuous discharge,  washing  away  of  the  entire  drum,  frequently 
evacuation  of  the  ossicles  and  permanent  deafness. 

Treatment. — The  indications  for  treatment  as  soon  as  diag- 
nosis is  established  are  very  clear ;  prompt  and  efficient  drainage 
should  be  established  as  early  as  possible,  and  maintained,  and 
extension  of  the  inflammatory  process  stopped  if  possible. 

The  local  application  of  heat,  continuous  irrigation  with  hot 
saline  solution  for  10  or  15  minutes,  or  perhaps  the  administra- 
tion of  an  anodyne  may  be  needed  for  the  relief  of  the  pain. 
In  some  cases  leeches  can  be  employed  with  advantage,  but 
the  child  should  not  be  allowed  to  see  them  or  told  what  is 
being  done  when  they  are  applied.  As  soon  as  a  bulging  of  the 
drum  has  been  diagnosed  a  free  incision  should  be  made,  and, 
as  suggested  in  the  previous  section,  this  should  not  be  done 
except  under  a  general  anesthetic.  It  is  a  most  painful  opera- 
tion ;  a  view  of  the  drum  cannot  be  satisfactorily  obtained  with- 
out it,  and  if  done  without,  and  great  pain  caused,  the  child 
will  be  intolerant  of  examination  and  treatment  for  years  after- 
ward. Early  evacuation  of  the  pus  by  paracentesis  limits  the 
chances  of  extension  of  the  process  to  deeper  structures  from 
pressure  of  the  pent-up  secretion. 

Frequent  examination  of  the  drum  should  be  made  after  para- 
centesis to  note  the  changes  occurring  in  the  drum,  the  tendency 
of  the  opening  to  close,  etc. 

The  patient  should  be  confined  to  bed  during  the  active  stage 


DISEASES   OP   THE   EAR. 


183 


of  inflammation.  The  child  should  have  a  pledget  of  cotton  in 
the  external  auditory  canal  and  a  pad  of  gauze  covering  the 
entire  external  ear,  this  confined  by  a  bandage  over  the  head. 

Lying  with  the  affected  side  down  is  a  great  aid  in  drainage. 
Frequent  irrigation  is  of  great  benefit,  at  least  every  three  hours 
at  first. 

The  following  table  given  by  Barnhill  gives  excellently  the 
differential  diagnosis  of  the  three  forms  of  trouble  just 
described : 

DIFFERENT  DIAGNOSIS   OF   ACUTE  TUBOTYMPANIC   CATARRH,   ACUTE  CATARRHAL 
OTITIS   MEDIA,   AND  ACUTE   SUPPURATIVE  OTITIS   MEDIA. 

Acute  Tuhotympanio       Acute   Catarrhal  Otitis        Acute    Suppurative 
Catarrh.  Media.  Otitis  Media. 


Absent  in  the  ear;  usu- 
ally amounts  only  to 
a  sense  of  soreness  in 
throat,  as  of  foreign 
body.  More  or  less 
pain  along  course  of 
Eustachian  tube. 

Absent,  unless  the  tubo- 
tympanic  catarrh  is 
secondary  to  some 
other  ailment  as  a 
mild  form  of  measles, 
which  primary  dis- 
ease gives  rise  to  the 
fever. 

Moderate.  Patient  com- 
plains of  great  deaf- 
ness, however,  largely 
because  of  the  sud- 
denness  of   onset. 


PAIN. 

Severe  in  depths  of  the 
ear,  radiating  over 
side  of  head.  Worse 
on  lying  down.  Pain 
increased  by  blowing 
nose  or  coughing. 

FEVER. 

Temperature  usually 
elevated,  100°  F.  in 
infants  and  young 
children. 


DEAFNESS. 
Very  considerable  in  af- 
fected  ear. 


Very  severe,  of  lanci- 
nating, tearing  va- 
riety. Increased  by 
recumbent  position, 
by  coughing,  sneez- 
ing, blowing  of  the 
nose,  etc. 

Ranges  from  102  to 
104°  F.,  the  height  of 
temperature  depend- 
ing much  upon  the 
presence  of  some 
general  disease,  as 
measles,  scarlet  fever 
or  la  grippe. 

Very  great  in  affected 
ear.  Patient  very 
deaf  when  both  ears 
are  involved. 


Kone. 


PROSTRATION   OF   PATIENT. 

Usually  moderate.      Often  very  great. 


Sometimes 
able. 


consider- 


184 


THE  DISEASES  OP   CHILDREN. 


Present    and    often    se- 
vere. 


Greatly  retracted  in 
first  stage,  less  so  in 
second  stage.  In- 
flammation absent, 
vessels  along  handle 
of  malleus  sometimes 
injected.  After  ex- 
udation into  the 
tympanic  cavity  has 
occurred,  a  dark,  or 
sometimes  a  light 
line  may  be  seen 
crossing  membrane, 
and  indicating  level 
of  fluid.  All  land- 
marks present. 

Drum  membrane  sel- 
dom ruptured. 


None  except  after  para- 
centesis. 


Rarefied  in  first  stage. 
In  second  stage  fre- 
quently contains  a 
yellowish  scrum,  or 
ropy,  mucoid  ex- 
udate, which  is  visi- 
ble through  non-in- 
flamed  membrana 
tympani. 


TINNITUS,   VERTIGO,  ETC. 

Head  noises  not  a  prom- 
inent symptom  ex- 
cept in  later  stages, 
after  the  pain  and 
fever  have  subsided. 
Vertigo  and  nausea 
rare. 

DBUM   MEMBBANE. 

Little  or  not  at  all  re- 
tracted _  at  onset, 
later  is  bulging  over 
some  quadrant.  In- 
jected at  first,  and 
later  a  diffuse,  uni- 
form redness  covers 
whole  membrane. 

Landmarks  usually 
all  obliterated  with 
possible  exception  of 
short  process  of  the 
malleus. 


PERFOBATION. 

Drum  membrane  usu- 
ally perforated  after 
from  one  to  three 
days. 

DISCHABGE. 
Thin,  seromucous  dis- 
charge immediately 
after  rupture  or  para- 
centesis. May  later 
become  purulent 

from   infection. 

TYMPANIC  CAVITY. 

Contains  seromucous 
exudate,  which  bulges 
membrane,  but  is  not 
visildc  through  in- 
flamed membrane. 


If  present  in  beginning 
are  so  masked  by 
severe  pain  that  they 
are  not  mentioned. 
Sometimes  present 
during  convalescence. 


Intensely  reddened,  es- 
pecially in  upper  por- 
tion ;  swollen,  bulg- 
ing, opaque.  Land- 
marks all  obliter- 
ated. Drum  mem- 
brane may  be  largely 
destroyed  during  first 
two  or  three  davs. 


Always     present     after 
two  or  three  davs. 


Sanguinopurulent  at 
moment  of  perfora- 
tion, purulent  later. 
Usually  very  pro- 
fuse. 


Contains  pus.  ^Fucous 
membrane  greatly 
swollen,  with  ne- 
crotic areas  in  worst 
cases.  Incus  and 
hammer  sometimes 
carious. 


DISEASES   OF   THE   EAR. 


185 


Not  painful.  Immedi- 
ate and  marked  im- 
provement results  to 
hearing. 


Usually  accompanies  or 
follows  a  cold  in  the 
head  or  a  naso-phar- 
yngitis.  May  result 
from  mild  attacks  of 
exanthemata  or  ton- 
sillitis. 

Never  occurs. 


TYMPANIC  INFLATION. 

Painful.  Little  or  no 
improvement  in  hear- 
ing except  in  later 
stages. 

HISTORY. 

Accompanies  or  follows 
the  exanthemata  of 
moderate  severity, 
and  the  acute  tonsil- 
lar and  naso-pharyn- 
geal  inflammations. 

MASTOID  COMPLICATION. 

Seldom  occurs. 


Painful  and  should  sel- 
dom be  performed 
during  height  of  in- 
flammation. 


Follows  or  accompanies 
the       more       violent 

'  forms  of  the  ex- 
anthemata, la  grippe, 
ulcerative-  tonsillitis, 
diphtheria,   etc. 


Frequently  occurs. 


MASTOIDITIS. 

The  mastoid  is  but  poorly  developed  in  young  infants,  and 
fortunately  not  so  very  frequently  involved  as  later  in  childhood. 

Etiology. — Probably  less  than  1  per  cent  of  cases  of  mastoid- 
itis develop  without  being  secondary  to  acute  suppurative  mid- 
dle-ear disease.  Neglected  cases  of  suppuration  with  long- 
retained  pent-up  secretion  in  the  middle  ear  makes  infection  of 
the  mastoid  cells  an  easy  matter. 

Diagnosis. — This  is  not  always  easy,  and  many  factors  influ- 
ence one  in  a  diagnosis.  It  should  be  suspected  in  all  cases  of 
severe  and  prolonged  suppurative,  middle-ear  cases.  Constitu- 
tional symptoms  are  apt  to  be  more  severe  upon  the  develop- 
ment of  mastoiditis,  temperature  more  elevated,  pain  more  acute, 
with  swelling  and  tenderness  over  the  mastoid. 

Symptoms. — A  previously  free  discharge  may  cease  or  become 
much  lessened,  the  temperature  usually  rises  quite  high,  104°  F. 
or  105°  F.,  or  there  may  be  a  very  little  rise,  if  any. 
The  pain  or  discomfort  and  tenderness  are  quickly  located  behind 
the  ear,  which  is  shortly  followed  by  a  swelling  of  the  skin  just 
back  of  and  slightly  below  the  middle  point  of  the  back  of  the 
ear.  "A  sagging  of  the  posterior  superior  meatal  wall"  has 
been  suggested  as  a  fairly  constant  occurrence.  There  is  much 
restlessness  and  disturbed  sleep. 


186  THE   DISEASES   OF    CHILDREN. 

Prognosis. — This  condition  is  an  extremely  serious  one  and 
causes  great  anxiety  on  the  part  of  the  physician  or  specialist 
in  charge.  The  decision  as  to  employment  of  surgery  is  difficult 
to  make  and  requires  keen  observation  and  careful  consultation. 
Possible  meningeal  involvement  in  children  should  always  be 
borne  in  mind. 

Treatment. — Local  application  of  cold  over  the  affected  mastoid 
by  cloths,  small  ice  bags  or  specially-devised  ear  ice  bags  is  first 
indicated,  or  the  opposite,  heat,  may  be  equally  effective  in  re- 
ducing inflammation  and  easing  pain.  Sedatives  may  be  posi- 
tively necessary  but  should  be  used  with  great  caution  and 
conservatism.  Leeches  to  the  affected  side  may  be  serviceable  if 
applied  early  in  the  involvement. 

As  before  stated,  just  where  the  medical  treatment  fails  and 
surgery  is  indicated  is  a  fine  line  not  easily  differentiated,  and 
a  safe  rule  to  follow,  is  when  in  doubt  operate. 

A  competent  specialist  should  always  be  associated  with  the 
practitioner  in  these  eases. 


CHAPTER  X. 

DISEASES  OF  THE  EYE. 

Eyestrain. — The  prevalence  of  eyestrain  in  school  children 
is  but  little  appreciated  by  teachers,  parents  or  physicians.  The 
eyesight  should  be  systematically  tested,  in  all  school  children 
by  a  medical  examiner,  and  the, parents  of  those  found  deficient 
notified  and  requested  to  have  the  defect  corrected. 

Statistics  of  different  observers  ^  show  from  30  to  50  per  cent 
of  several  thousand  school  children,  systematically  examined, 
to  have  visual  defects,  who  could  use  glasses  for  close  work  with 
benefit  to  their  eyes.  It  was  found  an  average  of  11  per  cent 
of  school  children  wear  glasses.  Investigation  in  20,000  cases 
showed  that  7.3  per  cent  of  all  children  suffer  from  6/18  or 
worse  defective  vision.  Of  the  various  errors  of  refraction  the 
following  table  shows  the  result  in  2500  Philadelphia  school 
children  of  all  grades : 

Per  cent. 

Emmetropia 11.19 

Hyperopia,  simple  31.2.3  per  cent      1  _.   „. 

with  Astigmatism  42.81  per  cent  j 
Myopia,  simple  2.68  per  cent  ")  IS  70 

with  astigmatism  11.02  per  cent    j 
Mixed  astigmatism    1 .  07 

ireadaclu',  fatigue,  inability  to  concentrate  the  attention  or  to 
study  result  from  eyestrain,  and  a  careful  examination  should  be 
made  in  all  cases. 

BLEPHARITIS. 

Definition. — An  inflammation  of  the  margin  of  the  lids  which 
is  quite  frequent  in  children. 

Etiology. — An  infection  of  the  hair  follicles  is  usually  the  be- 
ginning of  the  process.     The  squamous  and  ulcerative  types  are 


^Cornell:   Monthly  Cvclopedi.a  of  Practical  Medicine,  March,   1908. 

187 


188  THE   DISEASES   OP    CHILDREN. 

recognized.  Predisposing  causes  are  eyestrain,  dust  and  smoke 
which  result  in  a  congestion  of  the  mucous  membrane  of  the  lids. 
The  exanthemata,  tuberculosis,  anemia  and  a  general  run-down 
condition  also  predispose  to  it.  It  is  usually  found  in  connection 
with  conjunctivitis,  both  catarrhal  and  phlyctenular,  and  often 
with  eczema  of  the  face.  ^ 

Symptoms. — In  the  milder  form  there  may  not  be  many  focal 
symptoms  beyond  a  scaliness  of  the  edge  of  the  lids,  which  carry 
away  a  few  hairs  when  brushed  off.  In  acute  cases  there  is  a 
burning  and  itching  sensation  of  the  margin  of  the  lids  and 
some  photophobia;  after  a  duration  of  some  days  the  edges  of 
the  lids  are  much  congested  and  swollen  and  bathed  in  a  thick 
yellowish  secretion. 

Treatment. — In  the  squamous  form  after  removal  of  the 
scales,  which  can  be  accomplished  by  washing  with  an  alkaline 
solution  and  soap,  or  softening  with  vaseline,  the  local  treat- 
ment can  be  begun.     The  following  can  be  used  to  advantage : 

IJ  Hydrargjri  oxidi  flav.  gr         viii 
Vaselini  5' 

M.  ft.  ung. 

In  the  ulcerative  form  they  may  need  the  application  of  a 
1  or  2  per  cent  solution  of  nitrate  of  silver  after  removal  of 
concretions.  Generally  a  tonic  treatment  is  indicated  with 
proper  hygienic .  surroundings. 

HORDEOLUM. 

Synonym. — Stye. 

Etiology. — An  infection  of  one  of  the  glands  of  the  eyelid 
or  an  eyelash  follicle  takes  place  from  an  invasion  of  the  staphyl- 
ococcus aureus  or  other  pus-producing  organism.  As  a  result 
of  the  inflammation  suppuration  takes  place,  and  frequently  a 
reinfection  results  with  a  succession  of  them.  As  predisposing 
cause,  blepharitis  marginalis  is  perhaps  the  most  frequent.  Eye- 
strain is  also  a  predisposing  cause. 

Symptoms. — Pain  of  a  stinging  or  smarting  character  and 
edema  of  the  lid  precedes  the  development  of  the  stye.  The 
"pointing"  of  the  abscess  is  usually  at  or  near  the  lid  margin. 


DISEASES   OP   THE   EYE.  189 

and  it  may  rupture  spontaneously  or  necessitate  an  incision  to 
evacuate  the  pus.  The  pus  is  usually  quite  thick  and  stringy 
in  character. 

Styes  may  develop  in  quite  young  children,  and  when  it  is 
considered  how  possible  it  is  for  an  infection  to  take  place  in 
the  child  as  it  plays  upon  the  floor  and  rubs  its  eyes  with  its 
fists  it  is  a  wonder  they  are  not  oftener  seen.  I  have  recently 
seen  one  in  an  infant  of  six  months. 

Treatment. — The  abortive  treatment  is  occasionally  success- 
ful, viz.:  Cold  applications  and  pulling  out  a  lash  when  root 
is  infected,  or  the  application  of  a  30-grain-to-the-ounce  solu- 
tion of  sulphate  of  zinc.  If  the  upper  lid  is  affected,  it  is  pulled 
down  over  the  lower  lid  and  the  solution  painted  over  its  edge 
with  a  cotton-covered  match  or  tooth  pick.  The  solution  is  not 
allowed  to  touch  the  conjunctiva  of  the  eye.  The  applications 
are  repeated  several  times  during  the  day. 

The  injection  of  carbolic  acid  to  abort  the  boil  cannot  be  even 
considered  in  the  child. 

If  a  blepharitis  marginalis  is  present  the  use  of  a  yellow 
oxide  of  mercury  ointment  (gr,  ii  to  3i)  may  bring  about  a 
cure  promptly  enough  to  prevent  a  stye  from  forming. 

If  the  edema  continues  and  the  collection  of  pus  does  not 
take  place  quickly,  much  relief  can  be  had  by  the  application 
of  poultices,  small  squares  of  flannel  wrung  out  of  hot  water 
and  laid  over  the  affected  eye.  As  soon  as  pus  formation  is 
assured,  it  should  be  evacuated  with  a  triangular  Imife.  The 
hot  applications  should  be  continued  while  there  is  a  free  flow 
of  pus,  and  this  followed  by  the  yellow  oxide  ointment. 

CONJUNCTIVITIS. 

Two  varieties  may  be  seen,  simple  catarrhal  conjunctivitis  or 
the  epidemic  or  contagious  conjunctivitis,  the  latter  being  called 
pink  eye. 

Etiology. — This  is  due  to  the  invasion  of  the  conjunctiva)  with 
bacteria,  the  pneumococcus  and  the  Weeks  bacillus  being  most 
frequently  the  cause.  Bacteria-laden  dust  may  be  the  active 
cause.  Common  use  of  towels  is  a  frequent  manner  of  dis- 
semination. 


190  THE   DISEASES   OF    CHILDREN. 

Sjmiptoms. — The  simple  catarrhal  form  is  much  milder  in  all 
its  symptoms,  and  in  its  duration  also.  There  is  a  burning  and 
smarting  of  the  eyes  and  lids,  and  a  feeling  as  if  something  were 
in  the  eye  and  that  lids  mu.st  be  rubbed  frequently.  There  is 
early  and  profuse  lacrimation,  and  the  lids  are  stuck  together 
when  the  child  awakens. 

In  the  acute  form  there  is  an  injection  of  the  entire  con- 
junctiva and  the  lid  mucous  membrane  is  frequently  much 
swollen.  When  the  lids  are  everted  the  conjunctival  surface 
will  be  found  covered  with  mucus  or  muco-pus.  It  is  rare  that 
only  one  eye  is  affected. 

Treatment. — Much  can  be  accomplished  by  local  treatment. 
The  eyes  should  be  irrigated  four  or  five  times  daily  with  a 
warmed  3  per  cent  solution  of  boracic  acid,  and  one  or  two 
drops  of  the  following  solution  dropped  into  each  eye  three 
times  a  day : 

IJ  Zinci  sulphatis  gr.  ss 

Acidi  boracici  gr.  x 

Aquae  comphorat. 

Aquae  destillat.  aa  5SS 

M.  ft.  sol. 

A  mild  boracic  acid  ointment  is  rubbed  into  the  lids  each  night 
or  before  the  child  is  put  to  sleep  during  the  day  in  order  to 
prevent  the  troublesome  matting  together  of  them. 

Argyrol  in  10  or  12  per  cent  solution  can  be  used  if  the  secre- 
tion is  profuse  and  purulent.  In  the  severer  cases  the  applica- 
tion of  cold  compresses  is  most  helpful  and  soothing. 

Protection  from  strong  light  and  winds  should  be  insisted  upon 
also,  and  no  reading  indulged  in. 

TRACHOMA. 

Synonyms. — Granulated  Lids;  Granular  Conjunctivitis. 
A  chronic  infectious,  inflammatory  condition  of  the  palpebral 
conjunctiva,  with  the  formation  of  oval  masses  in  the  membrane. 

Etiology. — This  disease  is  much  more  frequent  in  children, 
though  no  age  is  exempt.  Unhygienic  surroundings,  filth  and 
improper  food  predispose  to  it.  The  specific  organism  has  not 
been  isolated,  though  a  small  double  coccus  has  been  described 


DISEASES   OP   THE   EYE.  191 

by  Sattler,  and  a  fungus  by  Muttermilch.  The  latter  has  been 
termed  microsporosa  trachomatoriwi.  Indiscriminate  use  of  the 
same  towel,  especially  at  school  and  in  institutions  is  one  of  the 
ways  this  is  spread. 

Pathology. — At  first  there  is  a  minute  granular  hypertrophy 
of  the  mucous  membrane  of  the  lid  conjunctiva  without  involve- 
ment of  the  eye  conjunctiva  or  cornea.  There  follows  a  deep 
injection  and  thickening  of  the  mucous  membrane  and  develop- 
ment of  the  larger  granular  masses  or  follicles,  which  are  minia- 
ture lymph  glands.     After  a  varying  length  of  time  the  stage  of 


Fig.  46. — Roller  forceps  for  trachoma. 

cicatrization  follows.  The  granules  coalesce,  small  cicatricial 
bands  appear,  the  area  of  conjunctival  surface  is  less,  the  rough- 
ened lids  scrape  the  eye  and  ulcers  of  the  cornea  form.  Tra- 
choma occurs  with  rarity  in  the  negro. 

Symptoms. — During  the  first  of  the  granular  stage  there  may 
be  no  symptoms.  There  is  little  or  no  discharge,  and  the  lids 
do  not  adhere  in  the  morning.  After  the  granules  have  formed 
there  is  pain  in  the  eyelids  and  a  feeling  as  if  sand  were  in  the 
eyes,  discharge  is  profuse,  mucopurulent  in  character,  photo- 
phobia is  present  and  swelling  of  the  lids  takes  place.  At  this 
time  the  ocular  conjunctiva  becomes  injected.  The  lids  are 
everted  with  difficulty  owing  to  the  swelling  of  the  mucous  mem- 
brane. These  acute  symptoms  may  subside  spontaneously,  and 
the  condition  develop  into  a  more  or  less  chronic  one,  with 
slight  lacrimation  and  mucopurulent  discharge.  The  glands 
at  the  angle  of  the  jaw  and  behind  the  ear  may  become  enlarged. 

Prognosis. — Even  under  proper  treatment  the  prognosis  is 
not  very  good.  It  is  essentially  a  chronic  condition,  relapses 
are  frequent,  even  in  the  apparently  cured. 

Sequelae. — Opacities  and  pannus  of  the  cornea;  entropion  and 
ectropion;  distichiasis  and  symhlepJiaron. 


192  THE   DISEASES   OP    CHILDREN. 

Treatment. — Prophylaxis  is  of  the  greatest  importance.  In 
institutions,  children  with  trachoma  should  be  quarantined. 
Shower  baths  should  be  installed  in  all  institutions,  as  the 
bathing  of  several  in  one  tub,  as  frequently  will  occur  if  tub- 
bathing  is  practiced,  may  be  the  cause  of  its  dissemination.  Indi- 
vidual towels,  handkerchiefs  and  beds  should  be  insisted  upon. 

Since  the  introduction  of  the  newer  silver  salts,  protargol  has 
been  recommended  as  giving  good  results  in  the  acute  stage. 
Every  other  day  a  40  per  cent  solution  is  painted  over  the  dis- 
eased surface,  and  a  10  per  cent  solution  instilled  into  each  eye 
twice  daily.  Other  remedies  suggested  are  the  following:  Solu- 
tion of  bichloride  of  mercury  (1:5000)  painted  on  the  lids  and 
1:15,000  as  eyedrops;  formalin  (1:3000),  and  the  application 
of  sulphate  of  copper  crystal  direct  to  the  diseased  surface. 

Surgical  treatment  consists  in  the  use  of  the  roller  forceps, 
under  general  anesthesia. 

GRANULAR  CONJUNCTIVITIS. 

A  much  milder  form  of  conjunctivitis  than  trachoma  may  be 
encountered  in  which  there  is  a  deposit  of  very  fine  granules  in 
the  conjunctiva. 

The  symptoms  and  course  are  much  less  severe,  and  the  dura- 
tion shorter. 

Treatment. — The  response  to  treatment  is  usually  much  more 
prompt  in  this  variety.  The  silver  salts  are  efficient  and  bring 
a  speedy  cure  if  properly  applied.  They  are  used  the  same  as 
in  trachoma. 

VERNAL  CATARRH  OF  THE  CONJUNCTIVA. 

This  form  of  conjunctivitis  has  recently  been  recognized  by 
the  authorities. 

It  is  frequent  in  children  during  the  summer  months,  and 
consists  of  a  lymphoid  hypertrophy  of  both  the  palpebral  and 
ocular  mucous  membrane,  and  especially  around  the  cornea. 

It  is  intractable,  has  a  tendency  to  recur  and  passes  away, 
often  uninfluenced  by  treatment,  as  the  summer  heat  disappears. 


DISEASES   OP   THE   EYE.  193 

DIPHTHERITIC  CONJUNCTIVITIS. 

Etiology. — The  Klebs-Loefiler  bacillus  is  the  cause  of  this 
form  of  conjunctivitis,  but  it  rarely  exists  alone,  being  com- 
plicated by  other  pus-producing  organisms,  especially  the  strep- 
tococci and  staphylococci. 

Pathology. — The  process  in  the  conjunctiva  as  the  result  of 
the  invasion  of  the  Klebs-Loeffler  bacillus  is  the  same  as  in  other 
mucous  membranes.  The  formation  of  the  pseudomembrane 
occurs  within  24  hours  after  the  first  congestion.  The  super- 
ficial epithelia  are  destroyed  and  the  pseudomembrane  dips 
down  into  the  conjunctiva,  leaving  a  bleeding  surface  when  it 
is  detached.  The  ocular  conjunctiva  may  be  involved  in  the 
same  process. 

Symptoms,  Focal. — There  is  a  great  swelling  of  the  mucous 
membrane  of  the  lids,  with  intense  congestion.  Lacrimation  is 
not  profuse  at  the  first,  the  discharge  is  thick  and  blood  tinged. 
Later  the  discharge  becomes  thinner  and  purulent.  The  pseudo- 
membrane forms  in  24  or  36  hours.  Bacteriologic  examination 
may  be  needed  to  determine  the  exact  nature  of  the  condition. 

General. — The  child  looks  sicker  than  in  any  of  the  other 
conjunctival  inflammations.  There  is  an  elevation  of  from  2° 
to  5°  F.  in  the  temperature. 

Treatment. — As  soon  as  a  pseudomembrane  is  seen  2500  to 
3000  units  of  antitoxin  must  be  administered,  without  waiting 
for  the  result  of  the  bacteriologic  examination.  The  same  rules 
obtain  here  as  to  the  second  dose  of  antitoxin  as  in  pharyngeal 
or  tonsillar  diphtheria. 

For  great  ecchymosis,  cold  application  to  the  lids,  and  nitrate 
of  silver  solution,  1  to  1.5  per  cent,  to  the  conjunctivse  after  the 
removal  of  the  membrane. 

Ulcer  of  the  cornea  is  to  be  feared  if  the  swelling  of  the  lids 
is  marked  and  pressure  very  great, 

PHLYCTENULAR  CONJUNCTIVITIS. 

Synonyms. — Scrofulous  conjunctivitis;  eczematous  conjunc- 
tivitis. 

Etiology. — As  indicated  in  the  name   given  this  disease,   a 


194  THE   DISEASES  OP    CHILDREN. 

marasmie,  tubercular  or  otherwise  debilitated  condition,  pre- 
disposes to  this  form  of  conjunctivitis.  It  also  follows  or  com- 
plicates blepharitis  marginalis;  acute  conjunctivitis,  eczema  of 
the  face  or  lids.  The  staphylococcus  aureus  has  been  found  in 
the  fluid  of  the  phlyctenule.     It  rarely  occurs  in  adults. 

Pathology. — The  phlyctenules  are  nodules  on  the  conjunctiva 
or  cornea,  formed  by  an  accumulation  of  small  cells  on  the  base- 
ment membrane  and  pushing  up  the  superficial  epithelial  cells. 
An  enlargement  of  the  blood  vessels  occurs  and  they  radiate, 
spoke-like,  from  the  phlyctenule.  The  surface  of  the  phlyctenule 
or  nodule  softens  and  the  contents  escape,  leaving  a  small  ulcer 
on  the  conjunctiva  or  cornea. 

Symptoms,  Focal. — The  principal  symptoms  are  lacrimation 
and  photophobia.  There  is  some  discharge  which  runs  down 
upon  the  cheek  and  may  cause  an  eczematous  condition  there. 
A  nasal  catarrh  is  present  also.  There  is  usually  a  character- 
istic pose  in  these  cases,  the  child  burying  its  face  in  the  neck 
of  mother  or  nurse,  or  holding  eyes  in  bend  of  elbow.  The 
appearance  of  the  eye  is  described  under  pathology. 

General. — The  child  looks  run  down,  is  pale  and  anemic, 
tongue  is  coated,  and  the  digestion  may  be  upset. 

Treatment. — If  the  injection  of  the  conjunctiva  is  very  great 
a  solution  of  atropia,  1  or  2  grains  to  the  ounce  of  50  per  cent 
boracic  acid  solution,  may  be  instilled.  An  application  of  the 
yellow  oxide  of  mercury  ointment  (gr.  i  to  oi)  is  made  once  or 
twice  daily.  A  piece  of  the  size  of  the  end  of  a  match  is  put 
between  the  lower  lid  and  eyeball  and  the  lid  closed.  Dry 
calomel  may  be  applied  to  the  ulcer  with  advantage  when  it 
forms. 

Generally,  a  tonic  is  always  indicated  in  these  cases.  A  solu- 
tion of  the  hypophosphites,  glycerophosphates  or  cod  liver  oil  will 
be  of  benefit. 

The  diet  should  be  regulated  and  much  fresh  air  insisted  upon. 
Study  and  use  of  the  eyes  should  not  be  allowed.  Dark  glasses  in 
the  older  cases  will  give  great  comfort. 


DISEASES   OP   THE   EYE.  195 

OPHTHALMIA  NEONATORUM. 

Etiology. — Due  to  the  entrance  of  the  gonoeoccus  into  the  con- 
junctival sac  during  the  passage  of  the  head  through  the  cervix 
and  vagina.  The  colon  bacillus  or  the  pyogenic  organisms  may 
be  the  cause  of  a  milder  inflammation.  If  it  occurs  in  later  life 
it  is  caused  by  the  accidental  inoculation  of  the  eye  with  the 
gonoeoccus. 

Prophylaxis. — The  instillation  into  each  eye  of  1  drop  of  a 
2  per  cent  solution  of  nitrate  of  silver,  as  advocated  by  Crede, 
followed  by  an  irrigation  of  normal  salt  solution,  will  prevent 
ophthalmia.  Its  use  should  be  universal  and  not  reserved  for 
those  children  whose  mothers  are  suspected  of  having  a  specific 
vaginitis  at  the  time  of  the  labor. 

For  those  who  prefer  a  substitute  for  the  nitrate  of  silver, 
because  of  fancied  irritation  following  its  use,  a  10  per  cent 
argyrol  solution  is  recommended. 

Focal  Symptoms. — Usually  on  the  second  or  third  day  the  lids 
of  one  or  both  eyes  are  stuck  together,  and  when  separated  a 
profuse  discharge  escapes.  The  discharge  is  distinctly  purulent 
and  may  run  down  on  to  the  cheek.  The  lids  rapidly  become 
swollen  and  the  mucous  membrane  intensely  congested,  making 
it  diflficult  to  evert  them.  If  the  secretion  remains  pent  up  be- 
tween the  lids  an  ulceration  of  the  cornea  may  result. 

Great  pain  evidenced  by  crying  and  restlessness  is  present ; 
there  is  marked  photophobia,  and  unless  the  hands  are  pinned 
down  the  eyes  will  be  rubbed. 

Prognosis. — This  form  of  inflammation  is  one  of  the  most 
serious  to  be  encountered.  More  eases  of  blindness  result  from 
a  specific  conjunctivitis  than  any  other.  Magnus  reports  that 
24  per  cent  of  inmates  of  institutions  for  the  blind  in  Europe 
have  lost  their  sight  from  ophthalmia,  and  statistics  show  an 
equal  or  greater  number  in  this  country.  Upon  prophylaxis, 
and  promptness  of  treatment  alone,  success  depends. 

Sequelae. — In  the  .severe  cases,  as  a  sequence,  the  following 
conditions  may  be  found :  Anterior  staphyloma ;  ulceration  and 
necrosis  of  the  cornea  leaving  an  opacity  which  may  seriously 
impair  vision ;  or  an  anterior  synechia. 


196  THE  DISEASES  OP   CHILDREN. 

Case. — In  one  of  the  few  cases  in  my  experience  in  which 
I  failed  to  employ  the  Crede  method  of  prophylaxis,  an  ulcera- 
tion of  the  cornea  in  both  eyes  followed  a  severe  ophthalmia  and 
an  evacuation  of  the  contents  of  both  globes.  In  this  case,  an 
institution  one,  the  silver  was  not  used,  as  the  bottle  containing 
the  solution  was  turned  over  and  its  contents  lost.  When  it  was 
used  the  next  morning  it  was  too  late,  as  evidences  of  inflamma- 
tion were  present.  This  one  unfortunate  case  has  been  a  con- 
stant reminder  to  use  the  silver  in  the  eyes  of  every  new-born 
baby. 

Treatment. — Good  results  can  be  had  only  by  beginning  the 
treatment  promptly;  the  treatment  must  be  not  only  unremit- 
ting but  intelligently  prescribed  and  administered.  To  verify 
the  diagnosis  a  smear  of  the  purulent  discharge  should  be  made 
upon  a  slide,  stained  with  methylene-blue  and  examined  for 
the  gonococcus.  As  the  symptoms  are  so  rapid  in  development 
the  beginning  of  the  treatment  should  not  wait  upon  the  micro- 
scopic report. 

A  day  and  night  nurse  should  be  employed.  The  eyes  should 
be  irrigated  with  a  boracic  acid  or  normal  salt  solution  once 
every  hour  in  the  24.  The  first  thought,  if  only  one  eye  is  af- 
fected, should  be  to  prevent  the  infection  of  the  other.  The  child 
lying  upon  the  affected  side  with  face  held  over  a  basin,  the  solu- 
tion is  directed  into  the  inner  canthus  of  the  affected  eye,  with 
the  lids  opened  as  far  as  it  is  possible.  This  irrigation  should  be 
gently  done  to  avoid  abrasion  of  the  cornea,  and  the  fountain 
syringe  not  held  over  12  inches  above  the  head. 

Between  the  irrigation,  unless  the  secretion  is  thin  and  watery, 
the  eye  is  kept  covered  with  ice  cloths.  Cotton  goods  is  cut 
into  1-inch  squares,  and  these  are  kept  attached  to  a  block  of 
ice  in  a  basin  near  the  bedside.  As  they  are  removed  from 
the  eye  they  are  destroyed  and  fresh  ones  applied  every  15 
minutes.  This  treatment  has  been  objected  to  by  some  as  it  is 
thought  to  be  impracticable  to  apply  the  cloths  effectively,  but 
they  are  of  the  very  greatest  benefit  when  properly  applied.  - 

Silver  solution  in  some  form  must  be  applied,  nitrate  of 
silver  in  a  2  per  cent  solution,  or  argyrol  or  protargol  in  a  40 
per    cent   solution,    once    daily.     It   is   claimed   for  the   latter 


DISEASES   OF   THE   EYE.  197 

solutions  that  they  are  more  penetrating  than  the  nitrate.  The 
nitrate  can  be  used  in  the  morning  and  a  weaker  solution  (10 
to  20  per  cent)  of  argyrol  two  or  three  times  during  the  day. 

If  it  is  possible  to  do  so  the  solution  should  be  applied  to 
the  everted  lids  by  a  cotton  swab,  but  this  may  be  impossible 
on  account  of  the  great  swelling  of  the  lids.  In  this  event  the 
solution  should  be  instilled  as  thoroughly  as  possible. 

To  evert  the  eyelids  of  a  child  Vail  ^  recommends  the  fol- 
lowing method: 

The  surgeon  sits  with  the  child's  head  lightly  clamped  be- 
tween his  knees,  the  child's  body  in  the  lap  of  the  nurse,  sitting 
close  by  in  a  chair,  and  the  child's  hands  held  by  the  nurse. 
The  feet  are  allowed  to  kick  free.  The  entire  finger  nail  of 
the  left  index  finger  is  placed  on  the  lower  lid  and  the  finger 
crooked  so  that  the  pulp  of  the  finger  tip  will  just  override  the 
edge  of  the  lower  lid ;  then  the  upper  lid  is  gently  pushed  down- 
ward by  means  of  the  index  finger  of  the  right  hand,  placed 
at  the  upper  tarsal  rim,  until  the  free  border  of  the  upper  lid 
overrides  the  pulp  of  the  finger  tip  of  the  left  index.  Main- 
taining the  pressure  with  the  right  index  finger  when  this  posi- 
tion is  affected,  the  upper  lid  is  turned  inside  out  by  simply 
keeping  the  free  edge  of  the  upper  lid  against  the  pulp  of.  the 
index  finger  of  the  left  hand.  The  right  hand  is  now  free  to 
use  in  everting  the  lower  lid.  Having  everted  the  upper  lid, 
the  lower  is  easily  everted  by  making  pressure  downward  with 
the  right  thumb. 

The  protection  of  the  sound  eye  by  a  watch  crystal  held  in 
place  by  adhesive  strips  has  been  recommended  by  Buller,  and 
in  older  patients  is  practical.  The  hands  of  the  infant  should 
be  held  down  by  pinning  the  sleeves  to  the  front  of  its  dress. 

Regularity  of  feeding  and  tonic  treatment,  if  case  is  pro- 
longed, is  recommended. 

PTERYGIUM. 

This  is  an  uncommon  condition  in  children.  It  consists  of 
a  circumscribed  hypertrophy  of  the  conjunctiva,  quite  regularly 
triangular  in  shape,  containing  enlarged  blood  vessels,  and  the 


1  Journal  of  Ophthalmology  and  Otolaryngology,   December,    1907. 


198  THE   DISEASES   OF    CHILDREN. 

apex  of  the  area  pointing  toward  the  cornea.  The  vessels  enter 
at  the  base. 

Etiology. — Two  varieties  are  usually  described,  pseudopter- 
ygium  and  true  pterygium.  In  the  first,  the  condition  seems 
more  like  a  formation  of  cicatricial  bands  following  a  violent 
inflammation  such  as  a  gonorrheal  or  diphtheritic  conjunctivitis, 
or  trachoma.  The  latter  form  has  been  ascribed  to  the  long 
exposure  of  the  eyes  to  heat,  or  the  sun's  rays,  as  on  the  water, 
wind,  dust,  etc. 

Symptoms. — These  growths  usually  occur  on  the  nasal  side 
of  the  eyeball,  though  the  whole  horizontal,  central  area  of  the 
ball  may  rarely  be  involved.  The  growth  gives  practically  no 
pain  or  inconvenience,  but  is  very  unsightly. 

Treatment. — Surgery  offers  the  best  results,  and  excision  is 
the  best  method  of  dealing  with  it. 

DISEASES  OF  THE  CORNEA. 

Phlyctenular  Keratitis. 

Etiology. — The  same  conditions  causing  phlyctenular  con- 
junctivitis cause  a  phlyctenular  keratitis,  and,  in  fact,  they 
usually  occur  simultaneously.  It  occurs  most  frequently  be- 
tween the  ages  of  2  and  12  years. 

Symptoms. — The  same  symptoms  that  are  present  in  phlyc- 
tenular keratitis;  the  photophobia  and  lacrimation  are  more 
severe.  According  to  the  location  of  the  ulcer  is  the  sight 
affected.  If  over  or  near  the  pupil  the  sight  may  be  greatly 
impaired,  owing  to  the  opacity  of  the  cornea.  The  pose  referred 
to  in  the  description  of  the  conjunctival  variety  is  more  con- 
stantly maintained.  The  eyes  may  have  to  be  forced  open  for 
inspection  because  of  the  photophobia.  Lacrimation  is  profuse, 
and  mucopus  is  present  in  most  of  the  cases.  When  one  or 
more  phlyctenules  are  seen  at  the  margin  of  the  cornea,  over- 
lapping both  the  cornea  and  conjunctiva,  they  are  called  mar- 
ginal pJilyctennles. 

Treatment. — ^Atropia  instilled  into  the  eye  is  very  necessary, 
using,  perhaps,  a  slightly  stronger  solution  (gr.  ii  or  iii  to  f^i). 
Tlie  same  strength  of  yellow  oxide  of  mercury  ointment  is  of 


DISEASES   OF   THE   EYE.  199 

value  in  this  form.  Boracic  acid  irrigations  should  be  used  three 
or  four  times  a  day.  A  general  tonic  treatment  is  also  in- 
dicated. The  photophobia  may  often  be  overcome  by  immersing 
the  face  in  a  basin  of  cold  water  for  a  few  seconds  several  times 
a  day. 

Insterstitial  Keratitis. 

This  is  the  form  of  inflammation  of  the  cornea  first  described 
by  Hutchinson  as  occurring  in  congenital  syphilis.  It  occurs 
generally  in  children,  and  is  most  frequent  between  5  and  12 
years  of  age.     It  is  generally  bilateral. 

Pathology. — There  is  an  inflammation  and  infiltration  of  the 
cornea  with  formation  of  fine  blood  vessels  deep  in  the  corneal 
tissues,  and  an  injection  of  the  conjunctiva.  The  infiltration 
is  uneven.  There  may  be  an  opacity  of  the  entire  cornea.  If 
recovery  takes  place  there  may  remain  some  fine  lines  running 
through  the  cornea,  which  were  the  former  vessels. 

Symptoms. — There  is  lacrimation  and  photophobia  but  not 
much  pain.  Sometimes  there  is  a  spasm  of  the  lids.  Asso- 
ciated with  this  disease  are  the  peculiar  notched  or  Hutchinson 
teeth;  the  skin  lesions  occurring  in  syphilis;  the  facies,  and 
labyrinthine  deafness. 

The  duration  is  chronic,  recovery  rarely  occurring  sooner 
than  two  or  three  years.  Atropia  is  of  great  help  in  obtaining 
comfort  and  should  be  used  for  its  effect  two  or  three  times 
daily  in  solution  3  to  4  grains  to  the  ounce.  In  the  very  acute 
stage  the  patient  may  have  to  be  placed  in  a  dark  room,  but 
usually  comfort  can  be  had  by  use  of  dark  glasses.  Application 
of  hot  cloths  is  of  great  comfort,  in  presence  of  spasm  of  the 
lids.  Difference  of  opinion  exists  as  to  the  value  of  yellow 
oxide  of  mercury  ointment.  It  should  be  used  only  when  the 
severe  inflammatory  symptoms  have  subsided,  and  in  connection 
witli  massage  is  of  benefit. 

In  the  acute  inflammatory  stage  atropin  is  used  with  the  hot 
applications  on  account  of  the  probaliility  of  an  iritis  developing. 

Internally  niorcury  is  indicated  early  and  late  and  contin- 
uously for  a  number  of  weeks.  Iron  and  cod  liver  oil  are  also 
important,  in  connection  with  good  food. 


CHAPTER  XI. 

DISEASES  OF  THE  RESPIRATORY  ORGANS. 

FOREIGN  BODIES  IN  THE  RESPIRATORY  TRACT. 

Owing  to  the  frequency  with  which  children  place  foreign 
bodies  in  the  nose  and  mouth,  the  comparative  infrequency  of 
the  aspiration  of  these  bodies  in  the  bronchial  tubes  is  to  he 
wondered  at.  Any  small  body  may  find  its  way  into  a  bronchial 
tube,  as  a  glass  bead,  a  pea  or  bean,  a  pebble,  etc. 

Symptoms. — A  child  while  at  play,  usually  entirely  well,  is 
seized  suddenly  w'ith  a  paroxysm  of  coughing,  followed  by 
dyspnea,  which  may  be  quite  severe,  there  being  a  decided  blue- 
ness  of  the  face.  If  the  object  is  of  sufficient  size  to  obstruct 
the  larynx  the  child  will  succumb  from  asphyxiation ;  if  it 
lodges  in  a  bronchus,  there  may  be  no  more  than  frequent  repeti- 
tion of  the  paroxysmal  coughing.  Owing  to  the  large  size  of  the 
right  bronchus,  and  the  angle  at  which  it  arises  from  the  trachea, 
the  bodies  usually  lodge  on  this  side.  An  X-ray  examination 
may  be  necessary  to  locate  the  body,  provided  it  is  of  the  nature 
which  will  show  upon  the  negative. 

Physical  signs  may  aid  the  diagnosis.  If  the  obstruction  is 
complete  there  is  absence  of  the  respiratory  murmur  and  voice 
sounds  on  that  side,  though  at  first  there  may  be  resonance  due 
to  the  retention  in  the  vesicles  of  the  air  in  the  lung  at  the  time 
of  the  obstruction.  This  air  is  soon  absorbed  and  dulness  is 
found  over  the  entire  lung. 

Owing  to  the  irritation  and  bacterial  invasion  a  broncho- 
pneumonia is  very  liable  to  develop,  or  a  localized  abscess. 

Diagnosis. — With  the  history  detailed  above,  the  aspiration 
of  a  foreign  body  should  always  be  suspected.  The  presence  of 
a  paroxysmal  cough  of  very  sudden  onset  without  previous 
coughing  is  suggestive.  A  diagnosis  from  whooping-cough 
must  be  made,  which  should  be  easy,  as  whooping-cough  does 
not  begin  as  suddenly. 

200 


DISEASES   OF   THE   RESPIRATORY   ORGANS. 


201 


Treatment. — If  the  diagnosis  is  made  as  soon  as  the  aspira- 
tion occurs  it  may  be  dislodged  by  quickly  grasping  the  child 


Fig.     47. — Five-cent     piece     in     esophagus.      (Reproduced     through     courtesy     of     Dr 

Kdward  Bruce.) 

by  the  feet,  suspending  it  inverted  and  shaking  it.  If  not  at 
once  thrown  off  the  spasm  produced  in  the  glottis  prevents  its 
expulsion. 


202  THE   DISEASES   OP'    CHILDREN. 

If  the  foreign  body  can  not  be  dislodged  by  the  above  procedure, 
it  should  be  taken  to  a  hospital,  and  the  X-ray  picture  made 
as  it  furnishes  a  very  valuable  guide  to  the  operator. 

The  success  obtained  by  the  direct  inspection  of  the  trachea' 
and  bronchi  by  specially  devised  instruments  for  the  removal  of 
foreign  bodies  in  the  bronchi  is  remarkable. 

Killain  and  Jackson  have  devised  most  ingenious  and  useful 
instruments  for  direct  laryngoscopy,  tracheoscopy  and  broncho- 
scopy, which  with  the  skiagraph  as  a  guide,  and  direct  ilhunina- 
tion,  enables  the  operator  to  see  the  foreign  body  and  with 
specially  designed  forceps  it  is  grasped  and  removed. 

Jackson  gives  the  following  measurements  of  the  tracheo- 
bronchial tree: 

Child  Infant 

Diameter  trachea    8-10  mm  6-7  mm 

Length           "             6  em  4  cm 

"           Right  bronchus   2  cm  1.5  cm 

"           Left           "            3  cm  2.5  cm 

"           Upper  teeth  to  trachea   10  cm  9  cm 

"           Total  to  secondary  bronchus....  19cm  15cm 

ASTHMA. 

Bronchial  asthma  is  comparatively  infrequent  in  infancy, 
though  not  uncommon  in  childhood. 

Etiology. — In  this  condition  there  is  a  vulnerable  area  of 
mucous  membrane  and  an  abnormally  sensitive  nerve  center  and 
an  irritant  as  the  active  causative  factor.  The  vulnerable  area 
of  mucous  membrane  may  be  in  the  nares,  adenoids,  the  bronchi," 
or  the  gastrointestinal  tract. 

Symptomatology. — The  attack  is  not  unlike  that  seen  in  the 
adult.  It  may  be  preceded  by  a  rhinitis  or  a  bronchitis  or  an 
attack  of  acute  indigestion  with  or  without  vomiting.  There 
is  decided  dyspnea,  increased  in  the  recumbent  posture.  There 
is  difficulty  both  in  inspiration  and  expiration,  with  a  frequent 
tight  cough,  there  is  an  anxious  expression  and  the  .skin  is  moist 
with  more  or  less  cyanosis,  according  to  tlie  amount  of  obstruction 
to  the  breathing. 

Physical  Signs. — Inspection  shows  the  extraordinary  mascles 
of  respiration  being  called  into  play,  recession  of  the  suprasternal, 
supraclavicular  and  intercostal  spaces,  with  more  or  less  cyanosis 


DISEASES   OP   THE   RESPIRATORY   ORGANS.  203 

or  lividity.  On  palpatioti  rhonchal  fremitus  may  be  felt  if  there 
is  much  spasmodic  condition  of  the  larger  tubes.  On  ausculta- 
tion widely  distributed  dry  rales,  sonorous  and  sibilant,  are 
heard  on  both  inspiration  and  expiration  with  occasional  moist 
rales  in  the  larger  tubes.  Coughing  may  dislodge  the  mucus 
causing  the  moist  sounds,  or  the  point  of  intensity  of  these  may 
be  changed.  There  is  hyperresonance  on  percussion  due  to  the 
temporary  emphysema  present. 

Treatment. — Prophylaxis  is  of  great  importance.  Each  case 
should  be  carefully  studied  and  the  exciting  cause  or  causes 
determined  and  removed  or  remedied.  The  nose  and 
nasopharynx  should  be  rendered  as  normal  as  possible,  adenoids 
and  abnormal  tonsils  removed,  the  digestion,  and  stools  closely 
watched.  All  the  methods  for  the  prevention  of  bronchitis 
should  be  used,  fresh  air  especially  when  the  child  is  asleep, 
cool  sponge  baths  after  the  cleansing  bath,  followed  by  brisk 
friction. 

For  the  relief  of  the  spasmodic  condition  during  the  attack, 
it  may  be  necessary  to  resort  to  hypodermic  medication;  three 
to  five  minims  of  a  1 :1000  solution  of  adrenalin  chloride  has  been 
used  with  much  success;  nitroglycerine  or  occasionally  when  all 
else  fails,  a  very  minute  dose  of  morphine.  By  the  mouth 
ipecac  or  antimony  and  ipecac  (aa  gr.  1/100)  cough  tablets 
frequently  afford  much  relief. 

ATELECTASIS,  PULMONARY  COLLAPSE. 

This  is  a  condition  in  which  a  lobule  or  lobe  of  the  lung  is 
collapsed.  It  is  principally  found  in  new-born  infants,  though 
a  collapse  may  occur  at  any  time. 

Etiology. — A  plug  of  mucus  inhaled  by  a  new-born  with  its 
first  inspirations  may  lodge  in  a  bronchus  leading  to  an  alveolus 
and  completely  shut  off  the  air  from  this  part,  followed  by  a 
collapse  of  that  portion.  The  same  condition  may  occur  in 
bronchitis  in  later  life,  or  after  the  aspiration  of  a  foreign  body 
into  a  larger  bronchus. 

Pathology. — There  is  a  collapse  of  the  alveoli  of  the  lung, 
and  may  be  limited  to  a  small  area  singly  or  scattered  through 
the  lung.     The  affected  areas  are  like  liver  in  appearance,  and 


204  THE   DISEASES   OF    CHILDREN. 

are  depressed  below  the  general  surface  of  the  lung.     There  may 
be  small  areas  of  emphysema  surrounding  them. 

Symptoms. — In  the  new-born  there  may  be  no  physical  signs 
or  symptoms  by  which  the  condition  can  be  recognized  early. 
Later,  if  extensive,  there  is  a  sinking  in  of  the  chest  on  that 
side,  or  if  scattered  there  may  be  no  evidence  of  the  condition 
except  an  impairment  of  the  breath  sounds  over  the  affected 
area,  with  localized  dulness,  perhaps. 

In  late  cases,  and  extensive  collapse,  absence  of  breath  sounds, 
harsh  breathing,  dulness  and  collapse  of  the  chest  wall  are  diag- 
nostic points. 

Treatment. — The   prompt   removal    of   mucus   in    the    naso- 
pharynx of  the  new-born  will  prevent  its  aspiration  into  the 
bronchi,  inversion  of  the  child  and  obtaining  free  inspiration 
and  crying  aids  in  the  dilatation  of  the  bronchi  and  dislodging " 
of  dry  mucus  which  may  have  been  aspirated. 

In  older  children,  when  it  follows  bronchitis,  a  dose  of  ipecac 
for  its  physiological  effect,  the  mucus  being  dislodged  during 
vomiting,  is  efficient  in  dislodging  obstructing  plugs.  Frequent 
spanking  to  make  it  cry  and  cause  deep  inspiration ;  alternate 
hot-  and  cold-baths,  for  the  effect  of  causing  a  shock  to  the  skin, 
cause  deep  inspiration. 

ACUTE  CATARRHAL  BRONCHITIS. 

This  is  an  inflammation  of  the  raucous  membrane  of  the 
bronchi,  large  or  small,  or  both,  with  no  involvement  of  the 
peribronchial  tissue. 

Etiology. — The  primary  and  exciting  cause  is  some  micro- 
organism, as  the  influenzal  bacillus,  the  strepto-  and  staphylo- 
cocci, etc.  A  dust-laden  atmosphere,  draughts,  sudden  ex- 
posures with  chilling  of  the  entire  surface,  and  wet  feet,  may 
act  as  a  direct  exciting  cause.  It  may  occur  secondarily  to  the 
acute  exanthemata  and  to  diphtheria,  and  is  a  frequent  occur- 
rence in  children  who  are  the  subject  of  adenoids  and  chronic 
nasopharyngeal  catarrh.  Children  who  are  convalescing  from 
acute  attacks  of  diarrhea  are  prone  to  develop  bronchitis,  from 
lowered  resistance.  It  is  a  frequent  complication  of  whooping- 
cough,  increasing  the  severity  of  this  condition  greatly. 


DISEASES  OP    THE   RESPIRATORY   ORGANS,  205 

It  occurs  in  rachitis  and  other  nutritional  disorders  from  a 
lowered  power  of  resistance. 

Pathology. — There  is  primarily  a  swelling  of  the  mucous 
membrane  of  the  larger  bronchial  tubes,  with  deep  injection, 
followed  quickly  by  a  secretion  which  is  largely  serum  at  first, 
then  mu.copurulent  as  the  disease  progresses.  It  is  usually 
bilateral  and  rarely  in  patches,  even  when  the  smaller  tubes  are 
involved.  The  inflammation  is  limited  to  the  mucous  mem- 
brane, and  when  it  spreads  to  the  peribronchial  tissue  the  proc- 
ess becomes  a  bronchopneumonia.  If  there  is  a  plugging  of 
some  of  the  smaller  or  capillary  bronchial  tubes  the  portion  of 
the  lung  supplied  by  these  tubes  collapses. 

Symptoms. — If  there  has  been  a  primary  tonsillitis  or  laryn- 
gitis, a  low  fever  and  slight  cough  precede  the  active  symptoms 
of  the  bronchitis.  It  may  begin  as  an  acute  coryza,  with  sneez- 
ing, discharge  from  the  nose,  and  lacrimation.  In  mild  cases, 
in  which  the  process  is  chiefly  limited  to  the  larger  bronchial 
tubes,  there  may  be  but  few  symptoms,  malaise,  slight  rise  in 
temperature,  loss  of  appetite  and  cough.  A  child  under  five 
years  of  age,  uninstructed,  will  swallow  all  mucus  raised  in 
coughing. 

In  more  severe  cases  in  which  the  smaller  tubes  are  involved, 
the  child  is  acutely  sick  from  the  beginning.  There  may  be 
vomiting;  the  temperature  rises  to  102°  F.  or  103°  F.,  and  with 
the  development  of  the  cough  there  is  rapid  breathing,  with 
wide  dilatation  of  the  alae  nasi.  The  dyspnea  is  frequently 
severe,  and  if  any  coryza  exists  it  is  difficult  for  the  child  to 
nurse.  This  is  especially  true  where  there  are  nasopharyngeal 
adenoids. 

There  is  not  usually  a  wide  variation  in  the  temperature  be- 
tween morning  and  evening.  There  may  be  an  evening  drop 
and  a  morning  exacerbation  in  rare  eases.  The  temperature 
usually  lasts  four  or  five  days,  though  it  may  last  for  a  week. 
It  is  more  easily  controlled  by  hydriatic  treatment  than  the 
fever  of  bronchopneumonia. 

The  respirations  are  hurried,  frequently  as  high  as  80  per 
minute,  and  there  may  be  a  decided  pallor  of  the  skin  of  the 


206  THE   DISEASES   OP    CHILDREN. 

face.  When  asleep  the  skin  of  the  head  may  be  bathed  in 
perspiration. 

The  bowels  may  be  disturbed,  especially  in  young  children, 
and  the  actions  contain  much  mucus  which  has  been  swallowed. 

Physical  Signs. — Inspection  of  the  bared  chest  shows  in  severe 
cases  an  employment  of  the  extraordinary  muscles  of  respiration, 
and  if  there  is  much  spasmodic  contraction  of  the  bronchial  tubes 
a  recession  of  the  suprasternal  and  clavicular  notches.  The 
respiration  is  quite  hurried. 

Palpation  of  the  chest  in  the  first  stage  may  be  negative,  but 
during  the  second  stage  when  there  is  a  secretion  of  mucus 
and  mucopus,  rhonchal  fremitus  is  easily  felt,  owing  to  the  thin- 
ness of  the  chest  wall.  For  this  reason  and  because  of  the  large 
tubes,  percussion  is  of  little  assistance  as  a  diagnostic  measure  in 
this  and  some  other  of  the  pulmonary  diseases  of  childhood. 

In  the  first  stage,  before  secretion  has  occurred,  auscultation 
reveals  sonorous  rales  if  only  the  larger  tubes  are  affected,  and 
sibilant  rales  when  the  smaller  tubes  are  involved.  Those  rales 
are  general  in  distribution,  but  heard  loudest  at  the  apex.  With 
the  advent  of  the  second  stage  on  the  second  or  third  day,  with 
mucus  thrown  out,  moist  rales  are  heard.  They  are  large  and 
small  according  to  the  lumen  of  the  tube  involved.  If  coughing 
occurs  when  auscultation  is  being  performed,  a  small  area  of 
lung  may  be  found  free  from  rales  entirely  for  a  short  while. 

Through  the  rales  may  be  heard  the  normal  vesicular  breath- 
ing, though  over  the  suprascapular  and  interscapular  regions 
the  vesicular  sound  is  replaced  by  a  harsh,  high-pitched  expira- 
tory sound  simulating  bronchial  breathing.  This  fact  should 
be  borne  in  mind. 

Diagnosis. — The  principal  diagnosis  is  from  a  hronclio- 
pneumonia,  which  may  not  be  possible  clinically.  A  localiza- 
tion of  the  physical  signs  of  bronchitis  and  a  continuation  of 
the  above  symptoms  beyond  four  or  five  days  is  very  suggestive. 
Dulness  over  a  limited  area  is  also  suggestive  of  consolidation  or 
collapse  of  a  more  or  less  large  area  of  lung.  In  pneumonia 
there  is  more  dyspnea  and  the  expiratory  grunt  more  likely 
to  be  present. 

Prognosis. — Older   children   with   acute   catarrhal  bronchitis 


DISEASES   OF    THE    RESPIRATORY   ORGANS. 


207 


usually  recover  promptly  in  four  or  five  days;  in  infants,  until 
entire  subsidence  of  symptoms  the  condition  should  be  con- 
sidered serious,  because  of  the  possibility  of  an  extension  of  the 
process  through  the  thin  bronchial  wall  and  the  development  of 
a  bronchopneumonia. 

In  the  secondary  cases,  especially  following  measles,  the  prog- 
nosis should  always  be  guarded. 

Treatment. — The  child  should  be  kept  in  one  room,  if  pos- 
sible, heated  by  an  open  fireplace,  with  windows  open  at  the 


Fig.    48. — Vaporizer. 

top  and  the  temperature  kept  as  evenly  as  possible  at  between 
60°  F.  and  65°  F.,  never  as  much  as  70°  F.  The  patient  should 
be  kept  in  bed,  and  several  times  a  day  a  tent  made  over  it  with 
a  sheet  and  the  air  impregnated  with  moist  air  from  a  so-called 
croup  kettle  or  steam  spray,  which  can  be  medicated  with  ben- 
zoin or  eucalyptus. 

But  little  internal  medication  should  be  given,  beyond  a 
preliminary  calomel  purge.  Frequent  doses  of  syrupy  cough 
mixtures  have  no  place  in  the  treatment  of  bronchitis. 

During  the  first  stage  the  following  tablet  is  of  decided 
benefit : 

IJ  Tartar  emetic 

Powd.   ipecac         aa  gr.   1-100 
Sacch  lactis  q.  s. 
M.  ft.  Tablet  No.  1. 


208  TPIE   DISEASES   OF    CHILDREN. 

These  may  be  given  every  two  hours  to  a  child  a  year  old, 
unless  vomiting  occurs.  Dover's  powders  in  small  doses,  gr.  -^ 
or  ;|,  or  codeine  sulphate,  gr.  ^  or  ^,  may  be  given  when  the 
child  is  put  to  bed  for  the  night,  if  the  cough  is  so  persistent 
as  to  prevent  its  sleeping.  In  the  presence  of  a  sensation  of 
tickling  in  the  throat,  adding  to  the  cough,  the  application  of 
a  cold,  wet  compress  to  the  neck,  protected  by  a  wide,  dry 
flannel,  is  of  great  benefit. 

No  medicinal  antipyretics  should  be  given,  the  temperature 
controlled  by  hydrotherapy  entirely. 

Counter  irritation  of  the  chest  is  of  the  greatest  benefit,  mus- 
tard plaster  giving  the  best  results.  One  part  of  Coleman's 
powdered  mustard  is  mixed  with  6  or  8  parts  of  flour  into  a 
thick  paste  with  cold  water,  spread  between  two  thin  layers 
of  cloth,  warmed  before  the  fire  and  applied  to  the  skin.  An 
edge  is  lifted  from  time  to  .time  to  ascertain  the  depth  of  the 
redness  of  the  skin.  When  the  skin  is  quite  red  the  plaster  is 
removed  and  the  surface  greased  with  vaseline.  Enougli  paste 
should  be  mixed  to  make  two  plasters,  which  are  applied  back 
and  front  at  the  same  time.  They  are  very  soothing,  as  a  rule, 
to  a  restless,  dyspneic  child,  until  they  begin  to  burn,  and  help 
the  cough.  They  should  be  reapplied  when  the  skin  is  pale 
enough  to  allow  it,  probably  as  often  as  every  six  hours.  With 
scanty  urine,  a  teaspoonful  of  liq.  ammon.  acetatis  in  water 
every  three  or  four  hours  is  of  benefit. 

Stimulating  expectorants  can  be  given  older  children  when 
the  secretion  has  changed,  as 

B  Ammon  carbonat  3s8 

Vin  ipecac  5ii 

Syr.  laurecerasi  5ss 

Aquae  dest.  q.  s.  ad       5" 
M.  ft.  Sol. 
Sig.     One  teaspoonfnl  every  tliree  hours. 

Prophylaxis  is  of  the  greatest  importance.  Children  subject 
to  lymphatism  with  adenoids  and  enlarged  tonsils,  should,  in 
the  spring  or  summer,  have  these  removed.  The  importance  of 
fresh  air  should  be  emphasized ;  children  should  not  be  started 
to  school  under  seven  years  of  age.     They  should  have  a  daily 


DISEASES  OF   THE   RESPIRATORY   ORGANS.  209 

morning  bath,  followed  by  a  cool  sponge  and  a  brisk  rub  until 
a  vigorous  reaction  is  obtained.  The  cold  spinal  douche  is  a 
great  shock  and  not  well  borne  by  the  average  child. 

The  sleeping  of  the  child  out  of  doors  should  be  encouraged, 
the  only  consideration  being  that  it  be  protected  from  draughts 
and  wind. 

The  sleeping  room  at  night  should  preferably  not  have  been 
used  during  the  day,  and  if  it  has,  should  be  thoroughly  aired 
before  the  child  is  put  to  bed.  The  temperature  should  not  be 
above  65°  F. 

The  barbarous  custom  of  "hardening"  a  child  by  keeping  it 
without  shoes  or  stockings  at  all  seasons  is  responsible  for  many 
of  these  attacks. 

Older  children  in  colder  climates  should  wear  under- 
drawers  as  soon  as  bladder  control  has  been  established,  as 
there  is  always  a  space  from  stockings  top  and  drawers  entirely 
uncovered. 

CHRONIC  CATARRHAL  BRONCHITIS. 

This  affection  is  a  direct  sequel  of  an  acute  bronchitis  and 
occurs  in  older  children  who  are  the  subject  of  nutritional  dis- 
orders, as  rachitis,  lymphatism  or  organic  heart  lesions,  syph- 
ilis, etc. 

Pathology. — There  is  a  chronic  thickening  of  the  mucous  mem- 
brane, and  numerous  patches  of  dilated  bronchi  constituting 
either  a  local  or  a  general  emphysema.  The  mucous  membrane 
is  bathed  with  mucus  and  mucopurulent  secretion. 

Symptoms. — Cough  is  the  principal  symptom,  and  this  is  fre- 
quently more  distressing  at  night;  expectoration  in  older  chil- 
dren is  sometimes  profuse ;  the  cough  may  be  paroxysmal ; 
dyspnea  is  often  present;  usually  there  is  a  very  slight  rise  in 
temperature,  not  often  more  than  100°  F.  There  is  pallor  and 
a  clammy  skin,  the  child  is  listless  and  has  very  little  endurance, 
showing  little  tendency  to  exercise  or  exhibiting  great  fatigue 
with  an  increase  of  coughing  on  exertion. 

Physical  Signs. — On  inspection  there  is  noticed  a  tendency  to 
bulging  of  the  intercostal  spaces  from  the  emphysematous  con- 
dition. 


210  THE   DISEASES   OF    CHILDREN, 

Percussion  shows  an  exaggerated  resonance  over  the  whole 
pulmonary  area. 

On  auscultation  the  respiratory  murmur  is  feeble,  and  numer- 
ous dry  and  moist  rales,  large  and  small,  are  heard,  which  may 
be  displaced  on  coughing. 

Diagnosis. — The  chief  differential  diagnosis  is  from  pulmo- 
nary tuberculosis.  In  chronic  bronchitis  the  physical  signs  are 
general,  the  temperature  not  apt  to  be  as  high,  the  wasting  not 
as  rapid,  the  expectoration  more  profuse.  The  tuberculin  re- 
action may  be  of  assistance  in  making  a  diagnosis.  From  pertus- 
sis the  diagnosis  should  be  easy. 

Prognosis. — In  children  the  subject  of  lymphatism,*the  prog- 
nosis is  not  very  good.  If  the  cough  is  relieved  on  the  advent  of 
summer  the  prognosis  is  better.  It  is  rendered  worse  by  the 
development  of  any  intercurrent  disease. 

Treatment. — Nothing  is  of  so  much  avail  in  these  children  as 
a  change  in  climate,  even  though  it  be  slight.  Removal  in  the 
winter  to  a  warm,  salubrious  climate,  free  from  dampness  and 
winds,  in  the  pine  regions,  is  of  the  greatest  benefit.  A  place 
must  be  chosen  where  the  child  can  live  out  of  doors.  The  east 
coast  of  Florida,  the  Gulf  coast  along  Alabama  and  Mississippi 
shores,  or  the  pine  regions  of  North  and  South  Carolina  and 
Northern  Louisiana.  This  change  should  be  made  in  the  late 
fall  before  an  attack. 

Forced  feeding  where  this  is  possible  yields  excellent  results, 
eggs  and  milk  forming  the  basis  of  the  extra  diet.  Sweets  of 
all  description  should  be  denied  rigorously.  Cod  liver  oil  gives 
the  best  possible  results,  administered  pure,  15  to  30  drops 
after  eating,  if  possible. 

Iron  in  an  easily  assimilable  form  is  of  benefit. 

I^  Tinct.  ferri  chloriri        3iss 

Glycerine  3ss 

Aquse  dest.  q.  s.  ad        ^iii 
M.  Sig.     One  teaspoonful  diluted  after  eating. 

EMPHYSEMA. 

This  condition  is  a  dilatation  of  the  air  vesicles  and  is  asso- 
ciated with  bronchiectasis,  where  the  larger  and  smaller  bron- 


DISEASES  OF   THE   RESPIRATORY  ORGANS.  211 

ehial  tubes  are  dilated  from  a  long-standing  chronic  inflamma- 
tion of  the  bronchial  mucous  membrane. 

Etiology. — It  is  a  frequent  accompaniment  of  chronic  bron- 
chitis, and  occurs  as  a  complication  of  whooping-cough  from  the 
violence  of  the  straining  during  the  paroxysms  of  coughing. 

Pathology. — There  is  a  weakening  of  the  walls  of  the  bronchi 
and  air  vesicles  from  chronic  congestion  and  frequent  violent 
stretching  from  coughing.  When  limited  to  the  air  vesicles  it  is 
usually  termed  vesicular  emphysema,  and  in  this  event  the 
symptoms  are  much  more  severe.  The  bronchial  tubes  and 
vesicles  are  capable  of  acute  dilatation  without  serious  permanent 
damage,  and  in  such  conditions  as  whooping-cough  the  resiliency 
of  the  walls  of  the  tube  may  overcome  the  dilatation  as  the 
disease  subsides. 

Compensatory  Emphysema  always  is  found  in  the  over-worked 
portion  of  the  lung  in  pneumonia,  and  in  the  unaffected  side 
in  pleurisy,  with  effusion  or  atelectasis. 

The  lung  is  dilated,  the  diaphragm  displaced  downward  and 
the  chest  wall  bulging  to  accommodate  them.  In  the  severe 
form  there  is  a  breaking  down  of  the  intervesicular  walls  and  a 
coalescence  of  the  vesicles. 

Symptoms. — In  cases  of  chronic  bronchitis  in  which  the  breath- 
ing is  specially  labored,  and  there  is  noticed  a  change  in  the 
contour  of  the  chest,  emphysema  should  be  suspected.  There 
is  a  tendency  for  the  chest  to  assume  the  barrel  shape,  the  veins 
of  the  skin  enlarge,  dyspnea  is  a  frequent  early  sign,  and  the 
least  exertion  causes  fits  of  coughing  which  are  more  than 
usually  severe.  The  heart  is  dilated  and  its  action  often  rapid 
and  tumultuous. 

Expectoration  is  usually  profuse,  especially  on  awakening, 
and  there  may  be  nausea  with  a  severe  paroxysm  of  coughing. 

There  is  a  marked  increase  in  pulmonary  resonance  and  a 
feeble  respiratory  murmur,  which  has  lost  its  vesicular  quality. 
Vocal  fremitus  is  much  lessened  and  the  cardiac  area  of  dulness 
much  smaller  owing  to  the  overlapping  of  resonant  lung. 

Rales  are  generally  present  and  other  signs  of  bronchitis. 

Treatment. — This  is  largely  symptomatic;  eliminate  the  cause 
when  possible.     When  associated  with  bronchitis  this  must  be 


212  THE   DISEASES   OP    CHILDREN. 

relieved,  the  best  results  being  obtained  by  a  change  of  climate. 
The  cough,  of  itself  increasing  the  trouble,  should  be  controlled 
by  the  administration  of  a  pulmonary  sedative:  Codeine  sul- 
phate, gr.  l^  to  ^4,  to  child  of  three  or  four  years,  or  heroin 
hydrochlorate,  gr.  1^2  to  Y^^.  General  tonics  are  of  the  utmost 
importance,  fresh  air,  good,  nutritious  diet,  elimination  of 
sweets  entirely. 

Close  watch  must  be  kept  on  the  bowels,  as  constipation  is 
present  as  a  rule  and  aggravates  the  condition.  Regular  enemas, 
cascara  aromatic,  10  or  15  drops  in  water  at  bedtime. 

BRONCHOPNEUMONIA. 

Synonyms. — Bronchial  pneumonia;  lobular  pneumonia;  capil- 
lary 'bronchiiis ;  catarrJial  pneumonia. 

Etiology. — When  secondary  to  an  acute  or  chronic  bronchitis, 
there  is  an  extension  through  the  mucous  membrane  of  the  bronchi 
and  air  vesicles,  of  the  inflammatory  process.  It  may  be  secon- 
dary to  the  acute  exanthemata  or  diphtheria,  the  toxins  and 
organisms  themselves  setting  up  the  process.  The  following 
predispose  to  bronchopneumonia ;  malnutrition,  rachitis,  ade- 
noids, unhygienic  surroundings,  living  in  institutions. 

It  may  occur  entirely  independent  of  any  known  disease  as 
an  acute  primary  condition,  due  to  any  of  the  organisms  caus- 
ing inflammation  finding  lodgment  in  the  lung.  The  follow- 
ing organisms  have  been  localized  from  bronchopneumonia, 
pneumococcus,  staphylococcus,  streptococcus,  Klebs-Loeffler  bacil- 
lus, bacillus  coli  communis. 

Pathology. — There  is  an  inflammation  of  the  bronchial  mu- 
cous membrane,  the  peribronchial  tissue  and  the  air  vesicles. 
The  process  may  involve  a  single  lobe  of  the  lung,  a  more  or  lass 
superficial  area  of  the  posterior  portion  or  a  small  spot  at  any 
place.  Frequently  on  section  a  number  of  small  areas  of  con- 
solidation will  be  found,  with  smaller  areas  of  atelectasis,  and 
patches  of  emphysema  nearby.  The  cut  surface  is  dark  and  mot- 
tled and  frothy  mucus  or  mucopus  oozes  from  the  severed  bronchi. 
When  the  consolidated  spot  is  near  the  surface  there  is  always  an 
involvement  of  the  pleura.     This  area  is  roughened  and  covered 


DISEASES  OF   THE   RESPIRATORY  ORGANS.  213 

with  fibrin.  There  may  be  adhesions  between  the  two  pleural 
surfaces. 

The  bronchial  glands  are  usually  considerably  enlarged. 

Symptoms. — Primary  bronchopneumonia  begins  suddenly,  like 
lobar  pneumonia. 

In  severe  eases  the  attack  usually  begins  with  vomiting,  there 
is  a  cough,  though  this  is  not  always  a  prominent  symptom. 

Dyspnea  and  hurried  hreathing  are  prominent  and  early  symp- 
toms. The  temperature  is  irregular,  not  running  persistently  high 
as  in  lobar  pneumonia ;  it  may  reach  104°  F.  but  is  usually  below 
this.  Occasionally  there  is  no  fever.  The  pidse  is  accelerated  and 
the  respirations  hurried ;  the  ratio  is  usually  2  to  1  or  even  3  to  1. 
The  pulse  may  range  between  180  and  200  or  higher.  The  expira- 
tory grunt,  which  is  almost  pathognomonic  may  be  present,  but 
not  with  the  same  regularity  as  in  lobar  pneumonia ;  there  is  dila- 
tation of  the  alsB  nasi,  and  there  may  be  more  or  less  cyanosis. 
There  is  restlessness  and  prostration. 

If  the  pneumonic  condition  arises  as  a  secondary  disease  there 
is  an  evidence  at  once  that  the  child  is  sicker  than  it  has  been  for 
a  few  days ;  the  respiration  and  pulse  are  hurried,  the  tempera- 
ture rises,  cough  becomes  persistent  and  harassing.  The  cough 
is  dry  and,  except  in  older  children  when  secretion  is  profuse, 
there  is  no  expectoration. 

The  dyspnea  causes  restlessness  at  night  and  the  cough  se- 
riously interferes  with  sleep  also.  The  skin  is  generally  more 
moist  than  in  lobar  pneumonia,  often  severe  perspiration  is  seen, 
though  it  may  be  hot  and  dry.  The  cheeks  do  not  have  the  deep 
red  color  as  in  lobar  pneumonia,  but  are  more  cyanosed. 

There  may  be  marked  nervous  symptoms,  but  convulsions  in 
the  onset  are  rare.  The  bowels  are  not  as  a  rule  disturbed,  though 
there  may  be  a  diarrhea.  The  actions  are  thinner  as  a  rule  than 
noi-mal  and  may  contain  mucus.  When  there  is  a  distension  of 
the  gastrointestinal  tract  from  gas  the  dyspnea  is  further  in- 
creased. 

Physical  Signs. — No  two  cases  of  bronchopneumonia  present 
the  same  physical  signs.  These  may  vary  from  the  signs  of  a 
localized  bronchitis  to  a  frank  consolidation,  limited  to  a  small 
area  or  involving  the  most  of  a  lobe. 


214  THE   DISEASES   OP    CHH^DREN. 

Inspection  reveals  hurried,  often  labored  respiration,  pallor, 
dilatation  of  the  alae  nasi,  recession  of  the  suprasternal,  supra- 
clavicular and  intercostal  spaces,  but  without  wide  range  of 
motion  of  the  chest,  owing  to  the  emphysematous  condition  of 
the  lungs. 

On  percussion  there  is  an  increased  pulmonary  resonance  over 
all  except  the  consolidated  area,  due  to  the  compensatory  em- 
physema. Even  the  dulness,  found  usually  over  the  consolidated 
area,  is  much  diminished  on  this  account.  Owing  to  the  thin- 
ness of  the  chest  wall  of  the  infant,  percussion  is  not  as  valuable 
a  means  of  physical  diagnosis  as  in  older  children  and  adults. 
Percussion  should  be  performed  very  lightly. 

Palpation  may  reveal  rhonehal  fremitus  and  if  the  consolidated 
area  is  large  vocal  fremitus  may  also  be  felt. 

Auscultation  is  of  the  greatest  help  in  making  a  diagnosis.  As 
before  stated,  the  signs  "of  a  localized  bronchitis  are  very  suspi- 
cious. The  localized,  moist  rales  may  be  the  only  signs  heard 
which  are  sufficient  for  a  diagnosis,  when  taken  in  connection 
with  the  other  symptoms.  They  may  only  be  heard  on  crying  or 
deep  inspiration. 

Over  the  anterior  chest  but  little  may  be  heard,  unless  some 
consolidation  appears  here.  Owing  to  the  emphysema,  the  re- 
spiratory murmur  is  enfeebled.  Over  the  posterior  aspect,  es- 
pecially, every  variety  of  rale  may  be  heard,  with  areas  over  which 
pleuritic  friction  sounds  are  heard.  As  there  are  only  scattered 
areas  of  consolidation,  usually  the  breathing  is  high-pitched,  es- 
pecially expiration.  Voice  sounds  are  increased  and  the  sounds 
of  the  cry  are  exaggerated  very  much  over  this  area. 

Convalescence  in  some  eases  may  be  much  prolonged,  the  gen- 
eral symptoms  subside,  but  the  chest  condition  remains  un- 
changed, resolution  taking  place  very  slowly.  These  always 
cause  much  anxiety  to  the  physician  because  of  the  possibility- 
of  the  pulmonary  condition  becoming  tubercular.  The  child 
has  a  progressive  loss  in  weight  and  appetite,  there  is  pallor,  rest- 
lessness, and  possibly  diarrhea,  etc. 

Complications. — Bronchopneumonia  may  eventuate  in  an 
abscess  of  the  lung,  gangrene,  pleurisy  with  effusion,  empyema, 


DISEASES   OF   THE   RESPIRATORY   ORGANS.  215 

any  one  of  which  complicate  the  condition  greatly  and  render 
the  prognosis  most  unfavorable. 

Emphysema  and  bronchiectasis  may  result,  making  recovery 
difficult.  Otitis  media,  meningitis,  pericarditis,  endocarditis  may 
occur  as  a  complication. 

Diagnosis. — The  principal  diseases  from  which  a  bronchopneu- 
monia must  be  diagnosed  are  bronchitis,  pulmonary  tuberculosis 
and  lobar  pneumonia. 

Prom  bronchitis  the  diagnosis  is  usually  made  both  from  the 
physical  signs  and  the  symptoms,  though  at  times  it  may  be  dif- 
ficult to  reach  a  positive  conclusion  at  first.  The  signs  of  a 
bronchitis  are  usually  bilateral  and  general  in  distribution,  while 
the  signs  of  a  bronchopneumonia  are  localized  and  usually  found 
at  the  bases  posteriorly.  The  child  does  not  seem  so  ill  in  bron- 
chitis, though  at  first  the  temperature  may  be  higher.  The  course 
of  the  disease  is  shorter  in  bronchitis.  The  pulse  and  respiration 
ratio  is  not  so  widely  different  from  normal. 

In  lobar  pneumonia  the  onset  is  much  more  sudden,  but  fre- 
quently the  only  diagnostic  sign  will  be  the  uncomplicated  bron- 
chial breathing  at  one  place  only,  as  an  apex  or  base,  which  in 
lobar  pneumonia  is  so  frequently  the  chief  sign.  Patches  of 
high-pitched  breathing,  not  distinctly  bronchial,  with  rales  here 
and  there  is  very  suggestive  of  bronchopneumonia.  The  tem- 
perature in  lobar  pneumonia  runs  higher  persistently  and  does 
not  fluctuate  so  much  as  in  bronchopneumonia  and  ends  by  crisis. 
Lobar  pneumonia  is  more  frequently  a  primary  disease  than 
secondary. 

Pulmonary  tuberculosis  and  bronchopneumonia  may  at  first  be 
difficult  of  differentiation,  and  as  a  tubercular  infection  may  be 
engrafted  on  an  unresolved  bronchopneumonia,  it  is  difficult  to 
tell  where  one  begins  and  the  other  ends.  There  is  more  often  a 
history  of  prolonged  ill  health  in  tuberculosis  than  in  broncho- 
pneumonia, and  the  complication  of  a  meningitis  more  often 
encountered  in  tuberculosis  during  its  course.  In  a  prolonged 
pulmonary  tuberculosis  there  is  a  persistent  and  rather  regu- 
lar run  of  elevated  temperature. 

Every  case  of  unresolved  bronchopneumonia,  with  a  mild  rise 


216  THE   DISEASES   OF    CHILDREN. 

of  temperature,  should  be  viewed  with  suspicion,  and  one  of  the 
tuberculin  tests  made  to  clear  up  the  diagnosis. 

Prognosis. — The  prognosis  in  bronchopneumonia  is  not  nearly 
so  favorable  as  in  lobar  pneumonia.  Primary  bronchopneumonia 
is  less  fatal  than  secondary,  such  as  may  occur  as  a  complication 
of  the  exanthemata  pertussis,  diarrhea,  diphtheria,  etc. 

Dunlop  ^  reports  333  cases  of  bronchopneumonia  occurring  in 
the  Sick  Children's  Hospital,  with  a  mortality  of  28  per  cent. 
The  prognosis  is  influenced  by  the  following  conditions :  Age, 
worse  in  the  very  young;  the  extent  of  the  lung  involvement,  bad 
in  extensive  involvement;  previous  health,  when  previous  health 
has  been  poor,  and  when  there  have  been  nutritional  disorders,  as 
rickets,  or  a  gastrointestinal  disturbance,  the  prognosis  is  unfavor- 
able. 

The  general  course  of  bronchopneumonia  is  much  more  pro- 
longed than  lobar  pneumonia,  and  ends  by  lysis  in  practically 
all  eases. 

Treatment. — Hard  and  fast  rules  can  not  be  laid  down  for  the 
treatment  of  every  case.  In  a  general  way  those  measures  which 
will  best  support  and  nourish  the  child,  control  the  temperature 
and  decrease  respiratory  difficulty  will  bring  about  the  best  re- 
sults. 

The  best  ventilated  and  sunniest  room  in  the  house  should  be 
selected  for  the  sick  room,  as  far  removed  from  the  noise  of  the 
house  as  possible.  Quiet  is  very  essential.  The  child  should  be 
made  to  remain  in  its  crib  and  not  held  upon  the  lap,  as  it  can 
be  protected  much  better  from  the  air  from  the  open  windows  in 
the  crib,  by  crib  curtains  or  screen.  In  winter  warm  night 
clothes  should  be  worn.  There  may  be  much  objection  to  the 
fresh  air  but  firmness  and  reasoning  Avill  usually  gain  its  accept- 
ance as  a  part  of  the  sick  room  routine.  The  usual  cleansing 
bath  should  be  given  daily. 

The  diet  in  the  artificially  fed  should  be  reduced  in  quantity 
and  quality,  in  the  breast  fed  the  interval  between  feedings 
lengthened.  Soft  diet  w'ithout  meat  can  be  given  to  older  chil- 
dren.    Milk  should  be  the  basis  of  the  diet. 

Temperature. — Pyrexia  and  hyperpyrexia  if  greatly  adding  to 

1  British   Medical   Journal,    August   15,    1908. 


DISEASES  OF   THE   RESPIRATORY   ORGANS.  217 

the  discomfort  and  distress  of  the  patient,  can  be  best  controlled 
by  hydrotherapy.  After  taking  and  recording  the  temperature 
a  tepid  sponge  bath  can  be  given  with  the  child  between  blankets, 
with  alcohol  and  water,  at  a  temperature  of  about  95°  F.  to 
100°  F.  If  there  is  no  fall  in  the  temperature  thirty  minutes 
after  the  sponge  bath,  other  hydrotherapeutic  measures  may  be 
used ;  a  full  bath  reduced  from  110°  to  95°  F. ;  compresses  wrung 
out  of  water  at  temperature  of  90°  F.  applied  to  the  chest ;  cold 
pack  in  the  full  blooded,  sthenic  cases ;  mustard  baths  at  105°  F., 
for  the  cyanosed  poorly  nourished  cases.  Ice  bags  to  the  head  are 
of  service  in  hyperpyrexia  and  when  there  is  delirium.  If  there 
are  scattered  areas  of  consolidation,  with  hyperpyrexia,  harassing 
cough  and  pleuritic  pain,  the  application  of  an  ice  bag  to  the  chest, 
on  a  half  hour,  off  an  hour  is  of  benefit. 

Local  Applications. — Poultices,  dehydrating  agencies,  oil  silk 
jackets  are  abominations  and  should  not  be  used. 

Counter  irritation  with  mustard  plasters  is  of  great  benefit, 
made  into  a  thick  paste  with  one  part  of  mustard  to  six  or  eight 
parts  of  flour,  mixed  with  water.  This  strength  will  not  blister 
or  burn  badly  if  removed  when  the  skin  is  a  deep  pink.  Fresh 
ones  can  be  applied  as  often  as  every  three  or  four  hours  if  the 
skin  is  normal  in  color  by  that  time. 

The  other  treatment  is  largely  symptomatic ;  if  the  cough  is 
very  persistent  and  annoying  at  night,  codeine  sulphate,  ^  or  % 
grain,  is  very  beneficial;  the  bowels  may  need  some  attention, 
castor  oil  at  the  beginning.  Ten  grains  of  bismuth  subnitrate 
every  three  hours  may  be  given  if  a  diarrhea  begins  during  the 
course  of  the  disease. 

The  heart  should  be  carefully  watched,  and  at  signs  of  heart 
failure  stimulants  administered  for  their  effect.  For  a  child  of 
one  year  any  of  the  following  may  be  given:  strychnia  %oq  to 
^/2uo  grain ;  tincture  of  strophantluis  one  or  two  minims ;  brandy 
twenty  to  thirty  drops,  any  one  of  which  may  be  tolerated  well 
by  the  stomach. 

Care  should  be  exercised  not  to  give  nauseous  doses  in  this 
condition,  too  much  depends  on  the  stomach  to  abuse  it. 

In  unresolved  pneumonia  it  is  most  imperative  that  a  change  of 
climate  be  had  as  soon  as  possible,  to  the  pine  regions  or  the  sea- 


218  THE   DISEASES   OF    CHILDREN. 

side  of  the  South.     The  child  should  remain  out  of  doors  con- 
stantly and  sleep  out  most  of  the  time. 

Cod  liver  oil,  iron  or  hypophosphites  are  valuable  agents  dur- 
ing convalescence. 

LOBAR  PNEUMONIA. 

Synonyms. — Croupous  pneumonia,  fibrinous  pneumonia,  lung 
fever. 

Etiology. — An  acute  primary  infectious  disease  involving  an 
entire  or  a  portion  of  a  lobe  of  the  lung,  due  to  an  invasion  of 
the  diplococcus  pneumoniae  or  the  pneumococcus  of  Friedlander. 
It  is  much  more  common  in  children  under  two  years  of  age 
than  is  generally  thought.  Riviere  shows  in  196  cases  during 
the  first  15  years  that  the  greatest  number  occurred  at  the  age  of 
two  years.  Season  is  a  contributing  cause,  it  being  more  prev- 
alent in  the  late  winter  and  spring.  Sudden  changes  in  the 
weather  and  exposure  are  predisposing  causes. 

Pathology. — The  process  in  the  lung  is  practically  the  same  in 
children  as  in  adults;  four  stages;  congestion;  the  stage  of  red 
hepitization,  in  which  there  is  filling  up  of  the  air  cells  and 
smaller  bronchi  with  products  of  inflammation  and  peribron- 
chial and  interstitial  involvement;  grey  hepitization,  with  soft- 
ening and  loosening  of  the  exudate ;  and  the  stage  of  resolution, 
in  which  there  is  a  removal  by  absorption  and  expectoration  of 
the  extravasated  mucus,  pus  and  detritus  accumulated  in  the 
bronchi  and  vesicles. 

Symptomatology. — The  onset  is  sudden  in  most  cases,  the  child 
becomes  suddenly  sick  without  any  distinct  prodromata,  as  a  rule, 
unless  it  be  vomiting  and  a  rigor.  The  rigor  may  not  be  noticed 
in  a  young  child,  save  by  cold  extremities,  which  may  be  over- 
looked. With  a  rise  in  temperature  there  may  l)e  a  distinct 
convulsion,  especially  in  those  children  who  are  highly  nervous, 
and  who  usually  give  a  history  of  convulsive  seizures  with  each 
illness,  in  which  there  is  a  rise  in  temperature.  Convulsions 
are  more  apt  to  occur  in  young  children  wdth  pneumonia  than 
in  older  ones. 

The  temperature  rises  quickly,  being,  as  a  rule,  higher  than 
in   bronchopneumonia,    frequently   reaching  103°    or   104°    F. 


DISEASES  OF   THE   RESPIRATORY  ORGANS. 


219 


There  is  an  excursion  of  from  1°  to  4°  F.  between  the  morning 
and  evening  records.  The  respiration  is  accelerated  from  the  be- 
ginning, frequently  being  seen  as  high  as  80  or  90  to  the  minute, 
in  fact,  this  symptom  may  be  the  first  noticed.  With  it  is  the 
characteristic  expiratory  grunt,  and  a  dilatation  of  the  alse  nasi. 


Fig.    49. — Lobar   pneumonia ;    crisis   seventh   day. 

The  pulse  is  accelerated  and  the  ratio  in  this  form  of  pneumonia 
between  pulse  and  respiration  is  greatly  disturbed;  it  may  be 
as  low  as  li/4  to  1,  though  3  to  1  is  more  frequent,  150  to  50 
being  a  frequent  record.  The  cheeks  are  flushed  and  often  the 
greatest  color  is  noted  on  the  cheek  on  the  same  side  as  the 
affected  lung. 

There  is  usually  considerable  prostration,  the  child  taking 
but  little  interest  in  his  surroundings.  The  urine  is  scant  and 
high  colored.  Cough  is  by  no  means  a  constant  symptom, 
though  it  is  very  often  present.  There  is  usually  no  expectora- 
tion even  in  older  children,  the  mucus  dislodged  being  swallowed ; 
when  expectorated  it  is  thick,  viscid  and  often  blood-stained.     If 


220  THE   DISEASES   OF    CHILDREN. 

there  is  an  involvement  of  the  pleura  over  the  affected  area  the 
cough  is  suppressed  as  it  is  very  painful,  and  the  breathing  is 
chiefly  diaphragmatic,  and  in  these  cases  the  expiratory  grunt  is 
more  pronounced.  With  a  pleurisy  there  is  often  a  fixation  of 
the  neck  and  upper  extremities,  as  moving  them  causes  more 
pain.     Abdominal  pain  may  be  complained  of. 

Constipation  is  the  rule  in  lobar  pneumonia,  and  the  opposite 
usually  in  bronchopneumonia.     Anorexia  is  the  rule. 

One  of  the  best  signs  as  to  the  amount  of  compensation  which 
exists  is  the  color  of  the  skin,  lips  and  lid  conjunctivce.  If  they 
remain  red,  in  spite  of  the  rapid  breathing  and  evident  dyspnea, 
nature  is  taking  care  of  things.  The  skin  is  usually  hot  and 
dry  with  no  perspiration  until  after  the  crisis. 

Termination. — The  termination  of  the  disease  is  usually  sud- 
den, by  crisis,  in  from  four  to  seven  days.  The  temperature 
may  fall  from  103°  or  104°  F.  to  normal  or  subnormal.  The 
temperature  may  show  a  slight  rise  after  this  drop,  which  is 
usually  designated  as  the  postcrisal  rise.  Some  obscure  and 
central  cases  of  pneumonia  may  be  of  very  short  duration,  the 
crisis  occurring  as  early  as  the  third  day. 

Physical  Signs. — The  pathognomonic  sign  of  the  first  stage 
of  pneumonia,  the  crepitant  rale,  is  not  heard  much  more  fre- 
quently in  children  than  in  adults,  as  the  case  is  usually  not 
seen  early  enough.  The  first  sign  noted  may  be  a  diminished  or 
distant  respiratory  murmur.  Inspection  reveals  the  rapid  breath- 
ing, dilatation  of  the  alae  nasi  and  flushed  face. 

Second  Stage. — Palpation  may  give  increased  vocal  fremitus 
if  the  area  of  consolidation  is  large  enough  and  near  enough  to 
the  surface.  There  is  dulness  on  percussion  over  the  consolida- 
tion and  an  increased  resonance  over  the  uninvolved  area.  The 
dulness  may  shade  off  into  the  resonant  area  gradually. 

Auscultation  reveals  the  typical  bronchial  breathing  over  the 
affected  area.  In  auscultation  over  the  apices,  posteriorly,  the 
normal  broncho-vesicular  breathing  of  this  region  must  be  borne 
in  mind.  The  use  of  the  stethoscope  with  small  bell  or  chest 
piece  is  urged  as  the  area  of  consolidation  which  is  near  the  sur- 
face may  be  small.  No  adventitious  sounds  may  be  heard  at  all, 
but  more  frequently  moist  rales  are  heard  on  the  edges  of  the 


DISEASES  OF   THE   RESPIRATORY  ORGANS.  221 

consolidation,  during  the  first  stage,  and  over  all  during  the  third 
stage. 

Care  must  be  taken  to  differentiate  the  kind  of  rale  heard  and 
its  location.  Very  frequently  there  is  an  involvement  of  the 
pleura  over  the  affected  side,  in  which  event  the  rales  are  small, 
fine  and  crackling,  and  very  close  under  the  stethoscope,  heard 
most  distinctly  at  the  end  of  inspiration  or  during  coughing. 
With  involvement  of  the  pleura  there  is  pain  on  coughing. 

Over  the  unaffected  portion  of  the  lung  there  is  an  exaggera- 
tion of  the  normal  vesicular  murmur. 

In  the  third  and  fourth  stages  the  bronchial  breathing  is 
fainter  and  there  are  many  rales  present,  the  rale  redux,  much 
like  the  rale  heard  in  the  first  stage. 

Resolution  may  rarely  be  delayed,  most  frequently  it  is  prompt 
and  complete  within  a  week  after  the  crisis.  Auscultation  at 
this  time  often  fails  to  reveal  any  difference  in  breath  sounds  in 
the  two  sides. 

The  most  frequent  site  of  the  consolidation  has  been  variously 
stated  by  different  observers.  Perhaps  the  left  lower  lobe  is  more 
often  affected,  next  the  right  upper  lobe,  then  the  right  lower  lobe. 
Apical  pneumonia  is  of  frequent  occurrence,  but  we  believe  it  is 
a  fallacy  to  expect  meningeal  complications  more  frequently  in 
apical  pneumonias  than  when  other  portions  of  the  lung  are 
affected. 

The  varieties  of  pneumonia  are  usually  classified  according 
to  the  physical  signs  and  the  symptoms.  Abortive  pneumonia 
is  that  form  in  which  a  crisis  occurs  within  a  few  hours  after  the 
initial  symptoms,  and  the  lung  clears  up  more  slowly;  or  there 
may  be  no  positive  signs  found  in  the  chest.  In  typhoid  pneu- 
monia the  case  is  a  prolonged  one  and  the  general  condition 
is  like  that  of  a  typhoid  fever,  but  without  any  symptoms  of 
typhoid,  save  the  low  state  of  the  patient.  In  relapsing  pneu- 
monia, after  a  short  period  of  remission  of  symptoms,  there  is 
an  exacerbation  due  to  an  involvement  of  new  areas.  This  in- 
volvement may  be  of  contiguous  lung  tissue  or  an  area  in  the 
opposite  lung  involved.  Pleuropneumonia  is  a  condition  where 
the  involvement  of  tlie  pleura  is  severe,  either  with  or  without 
extravasation  of  fluid. 


222  THE   DISEASES   OP    CHILDREN. 

The  complications  of  pneumonia  are  many  and  often  severe. 
Among  these  may  be  mentioned  pleurisy  with  effusion.  The 
entire  absence  of  sounds  over  any  area  of  the  lung,  especially 
the  base,  with  an  increase  in  the  dulness  is  always  a  suspicious 
occurrence,  and  effusion  into  the  pleura  should  be  thought  of. 
In  these  cases  the  resolution  is  delayed.  Exploratory  aspiration 
should  be  performed  in  obscure  cases.  Empyema,  otitis  media, 
pericarditis,  endocarditis,  peritonitis  may  occur. 

Meningitis  is  a  very  grave  complication.  As  before  stated 
meningeal  symptoms  are  not  more  frequent  in  apical  pneu- 
monia than  when  the  base  is  affected.  The  first  evidence  of 
meningeal  involvement  may  be  an  intense  headache  in  those 
children  old  enough  to  localize  pain,  with  restlessness.  There 
is  a  rise  in  temperature,  pupillary  symptoms,  perhaps  convul- 
sions, etc. 

Diagnosis  in  some  cases  of  deep-seated  pneumonia  is  at  first 
very  difficult,  as  no  physical  signs  are  present  to  aid.  It  has 
been  suggested  ^  that  the  X-ray  illumination  of  the  chest  is  a 
valuable  diagnostic  measure.  Three  forms  may  be  distinguished, 
(1)  lobar  or  fibrinous  inflammation,  (2)  disseminated  broncho- 
pneumonic  foci,  yield  no  shadow;  (3)  the  so-called  central  pneu- 
monias, which  yield  a  distinct  shadow  transillumination. 

The  principal  condition  to  be  diagnosed  from  is  a  hroncho- 
pneumonia,  which  has  been  mentioned  in  previous  pages. 

Appendicitis  may  be  suspected  from  localization  of  pain  in  the 
abdomen.      Careful  examination  of  the  chest  clears  this  up. 

Prognosis  is  good.  It  is  graver,  the  younger  the  child  affected, 
but  in  uncomplicated  cases  the  mortality  should  not  exceed  15 
per  cent  under  two  years  of  age  and  5  per  cent  in  children  of  all 
ages. 

Treatment. — There  is  no  specific  for  pneumonia,  but  much 
can  be  accomplished  to  alleviate  suffering  and,  I  believe,  to  hasten 
the  crisis. 

The  patient  should  be  placed  in  bed  at  once  in  as  large  and 
airy  a  room  as  possible  and  the  windows  thrown  open,  no  matter 
what  the  season  of  the  year.  Hot-water  bags  should  be  kept  to 
the  hands  and  feet,  and  the  patient  even  in  winter  not  too  heavily 


1  Weill-Shivenet    (Areh.   de   Med.   des   Enfants,    No.    7,    1907). 


DISEASES  OP   THE   RESPIRATORY  ORGANS.  223 

covered.  It  should  wear  an  undershirt  and  night  shirt  or  draw- 
ers. Oil-silk  jackets,  cotton- wadded  coats  and  poultices  are  not 
necessary,  and,  I  think,  positively  harmful. 

An  initial  dose  of  calomel  should  be  given  as  soon  as  the  child 
is  seen,  preferably  in  the  form  of  a  tablet  triturate,  finely  pow- 
dered, to  a  child  of  one  year  a  grain ;  2  grains  to  an  older  child. 
Castor  oil  may  also  be  used  to  advantage. 

For  temperature  above  104°  F.  there  should  be  given  a  sponge 
bath  followed  by  a  brisk  rub,  but  for  a  lower  temperature  the 
bath  need  not  be  given.  With  an  ice  bag  to  the  head  for  tem- 
perature above  103°  F.,  its  rise  is  frequently  prevented.  The 
use  of  ice  applied  to  the  affected  side,  as  advocated  by  Mays 
of  Philadelphia,  I  have  found  a  very  useful  measure  indeed. 

The  screw-cap  ice-bag,  partly  filled  with  crushed  ice,  wrapped 
in  a  towel  and  applied  to  the  consftlidated  area,  in  my  experi- 
ence, has  lessened  pain,  lowered  temperature  and,  I  believe, 
hastened  the  crisis  in  a  number  of  cases.  The  bag  is  applied 
and  removed  in  an  hour ;  on  an  hour,  off  an  hour,  being  the 
usual  rule. 

It  may  be  necessary  in  cases  of  severe  hyperpyrexia  to  use 
the  cold  pack  as  described  on  page  80.  Antipyretic  drugs  are 
mentioned  only  to  be  condemned. 

Heart  stimulants  should  not  be  given  as  soon  as  a  diagnosis 
of  pneumonia  has  been  made,  as  is  so  frequently  done.  Wait 
for  the  indication  and  give  it  for  that,  and  withdraw  it  as  soon 
as  possible.     Brandy  is  preferable  to  whisky,  and  should  be  pure. 

The  diet  should  be  liquid,  preferably  milk,  partly  skimmed 
and  diluted,  or  buttermilk  to  older  children.  Broths  may  be 
given  if  milk  is  not  tolerated  well,  an  occurrence  most  infre- 
quent. It  will  probably  be*  taken  in  small  quantity,  at  three- 
hour  intervals.     Give  all  the  cool  water  the  child  will  drink. 

In  the  presence  of  pain  from  pleuritic  involvement  a  mild 
sedative,  heroin,  in  Y^q  grain  dose,  to  child  of  one  year,  or 
codeine  sulphate,  %  grain  dose,  may  be  needed.  A  mustard 
plaster  applied  to  this  area  is  most  beneficial. 

The  condition  of  the  pulse  and  heart's  action  should  be  fol- 
lowed closely  throughout  the  attack.     If  cyanosis  is  present  there 


224  THE   DISEASES   OF    CHILDREN. 

may  be  a  condition  of  acute  dilatation  of  the  right  heart,  when 
a  prompt  dose  of  nitroglycerine  followed  by  digitalin,  hypoder- 
mically,  may  be  the  turning  point  toward  recovery. 

Strychnia  can  be  given  with  good  effect  but  should  not  be 
given  without  a  clear  indication  for  its  use. 

The  bowels  should  be  closely  watched  and  kept  freely  open, 
prompt  medication  given  when  indicated,  or  resort  had  to  en- 
emata. 

In  the  cyanotic  cases  oxygen  is  of  great  benefit  and  its  use 
should  not  be  postponed  too  long. 

Watchful  nursing  should  be  insisted  upon  after  the  fourth 
day  when  the  crisis  may  be  expected,  and  active  stimulation  used, 
if  needed,  at  this  time. 

After  the  crisis  and  resolution  has  progressed  satisfactorily, 
the  child  should  be  allowed  to  assume  the  upright  position  slowly. 
At  this  stage  the  following  prescription  may  advantageously 
be  used : 

H,  Ammoniae  chloridi  gr.  iv 

Syr.  ipecacuhana  3i 

Elix.  siraplicis  Jss 

Aquae  dest.  q.  s.  ad  pi 

M.  ft.  Sol.  Sig.     One  teaspoonful. 

Syrup  of  iodide  of  iron  or  syrup  of  hydriodic  acid  can  be  used 
to  advantage. 

PLEURISY  (PLEURITIS). 

This  is  either  primary  or  secondary,  and  may  be  of  a  simple 
fibrinous  variety,  or  there  may  be  a  serous  effusion  in  the  pleural 
cavity. 

Etiology. — It  has  been  said  by  some  observer,  ' '  Once  a  pleurisy 
always  a  pleurisy,"  implying  that  the  real  cause  of  a  pleurisy 
is  the  tubercle  bacillus,  and  that  every  case  of  pleurisy  should 
be  looked  upon  with  suspicion. 

It  is  surprising  how  frequently,  in  postmortem  work,  adhe- 
sions are  found  between  the  lung  and  costal  pleura,  evidencing 
an  old  pleurisy,  perhaps  recognized  at  the  time  but  afterward 
forgotten. 

Pneumonia,  the  pneumococeus,  being  the  active  causative  fac- 
tor ;  traumatism ;  the  exanthemata  are  frequent  causes  of  pleurisy, 


DISEASES   OF   THE    RESPIRATORY   ORGANS.  225 

the  streptococcus  and  staphylococcus  being  frequently  present. 
It  is  in  pleurisy  with  effusion  that  the  tubercle  bacillus  is  most 
often  found.  These  may  have  found  entrance  to  the  pleura  from 
the  bronchial  lymph  nodes,  the  intestinal  tract,  the  tonsils,  or  the 
trachea.  nU'./iV'l 

Pathology. — In  fibrinous  pleurisy  there  is  a  plastic  exudate 
over  the  affected  area,  with  cobweb  or  more  dense  adhesions  if 
the  ease  is  an  old  one.  In  the  sero-fibrinous  form,  with  effusion, 
the  fluid  when  aspirated  usually  flows  freely,  is  albuminous,  clear, 
and  of  a  greenish  tinge.  If  affected  with  pus-producing  organ- 
isms the  fluid  changes  in  character  to  pus,  constituting  an  em- 
pyema. 

Usually  but  one  side  is  affected,  though  there  may  be  an  effu- 
sion in  each  cavity. 

If  the  cavity  is  full  of  fluid  the  lung  is  compressed  and  dense 
like  liver,  sinks  in  water,  and  is  very  dark  in  color.  If  the  col- 
lection of  fluid  is  in  the  left  pleura  there  may  be  marked  dis- 
placement of  the  heart. 

Symptoms. — Pleurisy  occurs  more  frequently  in  children  over 
two  years  of  age.  In  primary  cases,  acute  in  onset,  there  may 
be  a  chill,  or  rigor,  pain  on  breathing,  especially  when  lifted  or 
turned  in  bed  or  on  deep  inspirations,  soon  a  hacking,  ineffectual 
cough  occurs,  and  there  is  fever  running  between  101°  P.  and 
102°  F.  though  it  may  be  as  high  as  104°  F.  Respirations  are 
quick  and  jerky  and  chiefly  diaphragmatic,  unless  the  diaphragm- 
atic pleura  is  involved.  There  is  great  restlessness,  and  constipa- 
tion is  present,  and  if  associated  with  tympany  the  breathing  is 
further  embarrassed. 

In  the  form  in  which  there  is  a  gradual  outpouring  of  serum, 
the  symptoms  are  not  so  acute,  the  temperature  lower,  and  as  the 
fluid  separates  the  two  inflamed  layers  of  pleura,  the  pain  is  less. 

The  location  of  the  pain  is  an  important  aid  in  diagnosis, 
and  often  misleading.  It  may  be  referred  to  the  shoulder  or 
to  the  iliac  region,  when  upon  the  right  side  being  suggestive  of 
appendicitis. 

In  this  kind  of  case  the  child  may  be  up  and  around,  but  list- 
less and  not  inclined  to  play  continuously. 

The  tongue  is  furred  and  the  appetite  capricious  or  lost  en- 


226  THE  DISEASES  OF   CHILDREN. 

tirely.  In  evident  tubercular  cases  the  clubbing  of  the  fingers 
is  soon  noticed. 

Physical  Signs.  Inspection. — Limited  movement  of  the  af- 
fected side  is  usually  apparent  in  the  first  stage  of  both  forms. 
Fixation  of  the  chest  is  present  in  eflfusion,  with  displacement 
of  the  apex  beat  of  the  heart. 

Mensuration  with  two  tapes  sewed  together  at  1  incli  will 
show  limited  expansion  of  the  affected  side. 

Percussion. — Only  with  effusion  will  there  be  much  change 
in  percussion  note  unless  there  be  a  thick  fibrinous  deposit  over 
the  pleura,  when  there  will  be  an  impaired  resonance,  if  not 
dulness.  Over  an  effusion  there  is  flatness,  an  entire  absence 
of  pulmonary  resonance.  With  a  large  effusion  a  line  of  de- 
marcation cannot  be  distinctly  made  out  as  the  pressure  on  the 
lung  and  collapse  of  the  bronchi  causes  a  loss  of  resonance  over 
the  lung.  There  is  exaggerated  pulmonary  resonance  over  the 
unaffected  side. 

Palpation. — In  pleurisy  sicca  friction  fremitus  can  be  felt. 
The  displaced  apex  beat  may  often  be  better  felt  than  located 
by  inspection.  Over  the  effusion  there  is  absence  of  vocal  frem- 
itus, with  probably  an  increased  fremitus  over  the  compressed 
lung  above. 

Auscultation. — If  done  early  in  both  forms  the  characteristic 
pleuritic  friction  sounds  are  heard,  varying  from  a  distinct 
crackle,  a  sound  like  pulling  two  pieces  of  buttered  bread  apart 
when  held  close  to  the  ear,  or  the  sound  of  creaking  leather. 
As  soon  as  effusion  takes  place  these  sounds  disappear  as  do  all 
breath  sounds.  There  is  nothing  so  eloquent  a.s  silence  over 
an  area  of  the  chest  where  normal  sounds  should  be  heard.  A 
high-pitched  breathing,  due  to  compressed  lung,  may  be  heard 
through  a  comparatively  small  layer  of  fluid.  Exaggerated  high- 
pitched  breathing  is  heard  over  the  compressed  lung,  above  the 
level  of  the  fluid  and  over  the  unaffected  lung,  due  to  the  com- 
pensatory work  done  by  it. 

Vocal  resonance  is  absent  over  the  effusion  but  increased  over 
the  compressed  lung. 

Diagnosis. — This  is  usually  easy,  especially  if  the  effusion  is 
in  fairly  large  quantity.     In  dry  pleurisy  there  may  be  some 


DISEASES   OF   THE   RESPIRATORY   ORGANS.  227 

doubt  as  to  the  exact  location  of  rales  heard,  whether  in  the 
finer  bronchial  tubes  or  in  the  pleura,  but  in  connection  with 
the  other  signs  the  differentiation  can  usually  be  made.  A  dis- 
placement of  the  apex  beat  of  the  heart  should  make  one  suspi- 
cious of  pleurisy  with  effusion. 

Prognosis. — The  usual  duration  of  an  acute  attack  of  dry 
pleurisy  is  from  4  to  10  days,  and  they  rarely  terminate  fatally, 
though  the  side  may  remain  indefinitely  crippled  from  adhe- 
sions. If  there  is  enough  effusion  to  cause  a  marked  displace- 
ment of  the  heart,  a  fatal  termination  may  result.  The  associa- 
tion of  tuberculosis  with  a  pleurisy  with  effusion  should  be  borne 
in  mind  and  a  guarded  prognosis  given. 

Treatment.— The  patient  should  be  put  to  bed  at  once  and 
an  initial  dose  of  calomel  given.  If  the  pain  is  excessive  it 
can  be  controlled  by  an  opiate,  Dover's  powder,  paregoric, 
heroin  or  morphine.  Such  relief  can  be  had  also  from  counter 
irritation  by  a  mustard  plaster  applied  over  the  site  of  the  pain, 
care  being  taken  not  to  raise  a  blister. 

Relief  can  also  be  had  in  some  cases  by  applying  an  adhesive 
plaster  strip  as  would  be  applied  over  a  fractured  rib,  limiting 
the  motion  of  that  side.  The  strip  should  be  applied  at  the  end 
of  a  deep  expiration. 

Aspiration  in  eases  of  effusion  should  be  done  only  in  those 
cases  in  which  there  is  no  evidence  of  absorption  at  the  end  of 
two  weeks,  or  where  there  is  great  dyspnea  or  marked  displace- 
ment of  the  heart  from  left-side  effusion.  Only  a  relatively 
small  amount  of  fluid  should  be  withdrawn,  the  point  of  selection 
being  the  interspace  about  the  middle  of  the  area  of  greatest  dul- 
ness,  the  patient  in  the  upright  position  if  possible,  leaning  for- 
ward to  hold  the  tissues  tense. 

The  skin  should  be  most  carefully  prepared  by  soap  and  water 
and  alcohol  and  the  needle  boiled.  The  aspirator  should  be  tried 
with  the  needle  in  sterile  water  to  be  sure  that  the  current  of 
suction  is  not  reversed.  The  upper  border  of  the  rib  should  be 
hugged  by  the  needle  to  avoid  the  vessels.  No  local  anesthetic 
is  needed,  as  a  rule,  though  ethyl  chloride  may  be  used. 

The  iodides  are  indicated,  syr.  iodide  of  iron  being  most  effi- 
cient, in  half  teaspoonful  doses  to  child  of  two  years. 


228  THE   DISEASES   OF    CHILDREN. 

Nourishing  food,  plenty  of  fresh  air  and  a  change  of  climate 
is  most  beneficial. 

EMPYEMA. 

A  collection  of  pus  within  the  pleural  cavity. 

Etiology. — This  may  be  the  result  of  an  infection  of  an  ex- 
travasated  fluid  in  a  pleurisy,  or  an  original  or  primary  infection 
of  the  pleura  due  to  the  pneumococcus,  streptococcus  or  staphylo- 
coccus. It  is  very  rarely  an  original  infection,  being  secondary 
to  pneumonia  in  fully  90  per  cent  of  cases.  It  may  also  compli- 
cate diphtheria  and  the  exanthemata,  in  fact,  any  infective  proc- 
ess may  cause  it,  tonsillitis,  pyema,  osteomyelitis,  etc.  It  may 
be  of  traumatic  origin.  In  children  the  tubercle  bacillas  is  more 
often  responsible  for  pleurisy  with  effusion  than  empyema.  It 
more  often  affects  children  between  six  months  and  three  years 
of  age,  although  no  age  is  exempt.  A  large  percentage  of  ef- 
fusions in  the  pleural  cavity  in  childhood  are  purulent. 

Pathology. — "With  a  large  collection  of  pus  as  in  pleurisy  with 
effusion  there  is  a  displacement  of  the  heart.  There  are  numer- 
ous adhesions  between  the  two  layers  of  pleura,  causing  saccula- 
tion. The  pus  is  thick,  a  very  dark  yellow,  and  many  lumps  may 
be  present.  This  fact  must  be  borne  in  mind  in  aspiration,  for 
either  diagnostic  or  curative  purposes. 

There  is  an  associated  unresolved  pneumonia,  the  consolida- 
tion being  more  of  the  lobar  than  the  broncho  type.  If  there  is 
much  fluid  there  may  be  a  compression  of  the  lung  without  con- 
solidation. 

An  infection  of  other  serous  cavities  may  complicate  an 
empyema,  a  pericarditis,  endocarditis,  peritonitis  or  synovitis. 
Bronchopneumonia  may  arise  as  a  complication,  especially  if 
there  is  a  rupture  of  the  fluid  into  the  lung. 

Symptoms. — In  primary  cases  the  onset  is  sudden,  a  chill  or 
rigor,  usually,  with  pain  and  dyspnea,  much  the  same  as  in  a 
pneumonia;  a  rise  of  temperature  to  103°  or  104°  F.  The  fever 
is  usually  irregular,  a  morning  remission  and  high  in  the  even- 
ing, followed  by  a  sweat.  It  must  be  borne  in  mind,  however, 
that  there  may  be  a  large  accumulation  of  pus  in  the  cavity  and 
a  comparatively  small  rise  in  temperature.     In  secondary  cases 


DISEASES   OF   THE   RESPIRATORY  ORGANS.  229 

there  may  have  been  an  apparent  improvement  in  the  pneu- 
monia followed  by  a  gradual  rise  in  the  temperature,  and  increase 
in  all  the  symptoms,  the  cause  of  which  may  not  be  clear  without 
a  careful  physical  examination.  The  cough  returns  and  becomes 
quite  annoying,  with  no  expectoration,  there  is  a  progressive  loss 
in  weight ;  some  pain  in  the  affected  side,  especially  when  taking 
a  long  breath ;  loss  of  sleep ;  no  appetite ;  restlessness ;  constipa- 
tion; anemia  and  a  tendency  to  clubbing  of  the  fingers.  There 
may  be  a  decided  interference  with  respiration,  so  the  child  has 
to  be  held  or  propped  partly  up  in  bed.  The  dyspnea  may  not 
be  noticed  markedly  unless  the  patient  is  moved,  or  turns  sud- 
denly in  bed.  This  is  specially  the  case  if  there  is  enough  effu- 
sion to  cause  a  displacement  of  the  heart  and  large  vessels. 

Physical  Signs. — There  are  no  essential  differences  in  the 
si^s  found  in  empyema  and  in  pleurisy  with  effusion,  save 
when  an  empyema  complicates  a  pneumonia,  owing  to  the  thick- 
ness of  the  fluid  and  its  better  conducting  power,  bronchial 
breathing  may  be  heard  through  it.  This  bronchial  breathing 
is  usually  more  distant  and  faint  than  that  heard  above  the 
level  of  the  pus  over  the  compressed  lung.  The  effusion  is  usu- 
ally at  the  base,  but  may  be  localized  at  several  points  owing  to 
the  possibility  of  adhesions  forming  and  the  fluid  becoming 
pocketed.  Collections  of  pus  at  the  apex  may  occur,  but  very 
rarely. 

Diagnosis. — The  diagnosis  is  principally  from  a  lobar  or 
bronchopneumonia,  and  pleurisy  with  effusion.  The  physical 
signs  are  to  be  relied  upon  principally  for  a  diagnosis.  In  lobar 
pneumonia  the  crepitant  rale  heard  early  may  be  mistaken  for 
a  pleuritic  friction  sound,  but  this  is  rapidly  followed  by  bron- 
chial breathing  and  dulness,  whereby  the  bronchial  breathing,  if 
heard  at  all  over  the  extravasation  of  fluid,  is  heard  late.  There 
is  no  displacement  of  the  heart  in  pneumonia,  the  percussion  note 
is  flat  in  empyema.  A  leucocyte  count  may  assist  in  the  diagnosis 
of  an  empyema.  The  polynuclear  percentage  is  high  in  empyema. 
From  pneumonia,  as  well  as  pleurisy  with  effusion,  it  may  re- 
main for  an  exploratory  puncture  to  clear  up  the  diagnosis. 
This  must  be  done  under  the  strictest  aseptic  precautions,  careful 
sterilization  of  the  needle  and  preparation  of  the  field  and  hands. 


230  THE   DISEASES   OF    CHILDREN. 

A  needle  of  suflfieient  size  should  be  chosen  to  allow  thick  pus  to 
flow  through.  The  point  of  election  for  an  exploratory  puncture 
is  in  the  sixth  interspace  in  the  posterior  axillary  line.  It  may 
be  necessary  to  examine  a  drop  of  the  fluid  microscopically  to 
definitely  determine  its  nature,  as  serous  pleural  effusion  is  often 
very  turbid,  resembling  pus. 

Prognosis. — This  can  be  said  to  depend  to  a  great  extent  upon 
the  promptness  of  diagnosis  and  the  method  of  treatment  em- 
ployed. Age,  previous  illnesses  and  cause  also  influence  the 
outcome  as  well  as  the  presence  and  nature  of  complications. 
In  cases  in  which  there  is  a  mixed  infection  the  prognosis  is  not 
so  good.     Pure  pneumococcus  infections  are  more  favorable. 

Treatment. — The  treatment  of  empyema  is  surgical,  and  three 
methods  are  in  vogue,  aspiration,  simple  incision  and  rih  resec- 
tion. Aspiration  should  not  be  resorted  to  except  as  a  diagnostic 
measure.  A  large  quantity  of  pus  may  be  withdrawn  but  its 
tendency  is  to  quickly  reform. 

As  the  indication  is  quick  removal  of  the  pus  as  soon  as  rec- 
ognized, the  best  method  of  removal  is  an  uwision  of  the  inter- 
costal space,  with  tube  drainage  afterward  until  the  pus  ceases 
to  flow.  The  point  to  be  selected  for  the  incision  should  be 
carefully  made,  the  object  being  to  have  the  opening  at  as  de- 
pendent a  point  as  possible,  bearing  in  mind  the  probable  saccu- 
lation of  the  fluid. 

Usually  the  seventh  or  eighth  interspace  is  chosen  about  the 
posterior  axillary  line,  and  the  incision  made  2  or  2i/2  inches 
long,  close  to  the  upper  border  of  the  rib,  this  being  advantageous 
in  avoiding  vessels  and  nerves,  and  is  more  convenient  in  case 
a  rib  resection  is  later  necessary. 

With  strict  aseptic  precautions  the  incision  is  made  under  a 
local  anesthetic,  cocaine  or  ethylchloride,  down  to  the  pleura. 
A  general  anesthetic  is  dangerous.  The  pleura  is  nicked  and 
the  opening  enlarged  with  an  artery  forceps,  and  a  considerable 
quantity  of  pus  allowed  to  escape.  Drainage  tubes,  previously 
prepared,  fenestrated  and  armed  with  large  safety  pins  in  the 
outer  end,  are  pushed  in  the  cavity,  and  the  remainder  of  the 
pus  allowed  to  flow  out  into  the  dressings,  which  are  immedi- 
ately applied.     Gauze,  absorbent  cotton,  waste  or  oakum,  make 


DISEASES   OF   THE   RESPIRATORY   ORGANS,  231 

good  dressings  in  the  after  treatment.  The  first  may  be  used 
wet  to  facilitate  absorption. 

Should  the  pus  be  very  thick  and  not  flow  freely  a  subperiosteal 
rib  resection  should  be  done.  This  requires  a  general  anesthetic. 
The  incision  is  slightly  enlarged,  the  rib  exposed,  the  periosteum 
elevated,  and  a  section  of  the  rib  1  or  2  inches  in  length  removed 
with  bone  forceps.  A  tube  is  then  placed  in  this  opening  and 
drainage  is  much  more  free. 

The  after  treatment  of  the  operative  cases  consists  in  daily 
or  more  frequent  dressing,  removal  of  the  tube  each  day  and 
cutting  off  from  half  an  inch  to  an  inch  and  replacing  it,  until 
by  the  end  of  the  week  it  can  be  removed  entirely. 

Irrigation  of  the  pleural  cavity  should  be  discouraged  always. 

Vaseline  or  oxide  of  zinc  ointment  can  be  used  to  advantage 
on  the  skin  around  the  opening  to  prevent  excoriation.  The 
tube  had  best  be  pinned  to  an  adhesive  plaster  strip  and  this 
applied  to  the  skin  to  prevent  its  slipping  into  the  cavity. 

On  the  removal  of  the  tube  for  good  a  small  strip  of  gauze 
should  be  carried  into  the  opening  for  a  few  days  to  prevent  its 
closing  too  quickly. 

Deformity  of  the  chest,  due  to  failure  of  the  compressed  lung 
to  properly  contract  after  evacuation  of  the  pus  is  sometimes 
seen. 

General  tonic  treatment,  fresh  air  and  judicious  feeding  is  of 
importance  in  the  after  treatment. 

GANGRENE  OF  THE  LUNG. 

This  is  a  rare  condition  in  children,  and  may  only  be  recog- 
nized at  the  autopsy  table. 

Etiology. — Some  process  has  been  present  in  the  lung  pre- 
viously, favoring  bacterial  invasion,  as  a  pneumonia  or  empy- 
ema, or  as  a  complication  of  noma,  the  exanthemata,  suppurative 
tonsillitis  or  middle-ear  trouble.  An  embolus  of  septic  origin 
may  be  a  cause. 

Pathology. — There  may  be  one  or  a  number  of  foci  of  gan- 
grene ;  the  areas  are  dark  in  color  and  the  fluid  present  is  green- 
ish in  color  and  very  foul-smelling.  There  is  an  area  of 
consolidation  usually  around  these  gangrenous  spots.     If  near 


332  THE   DISEASES  OF    CHILDREN, 

the  surface  a  pleurisy  generally  is  found,  and  they  may  ulcerate 
through  into  the  cavity. 

Symptoms. — These  may  be  obscure,  and  unless  a  bronchus  be 
invaded  by  rupture  of  a  gangrenous  area  and  some  of  the  fluid 
expectorated  the  condition  may  not  be  suspected.  This  fluid 
is  dark,  thick,  contains  pus,  blood,  mucus  and  lung  tissue,  and 
is  foul  smelling. 

If  complicating  or  following  a  pneumonia,  tlTtere  is  an  exacer- 
bation of  the  symptoms,  prostration,  usually  a  foul  breath,  in- 
crease in  fever,  quite  rapid  loss  of  flesh  and  strength,  and  sweats. 

Physical  Signs. — Unless  a  gangrenous  area  has  broken  down, 
forming  a  cavity,  the  signs  may  not  vary  from  those  fouud  in  a 
pneimionia.  In  this  even  cracked-pot  resonance;  amphoric  reso- 
nance, and  probably  gurgles  may  be  found. 

Treatment. — When  a  diagnosis  has  been  made  and  the  site  of 
the  trouble  located  positively,  a  pneumonotomy  is  indicated  fol- 
lowing a  rib  resection.  Tonic  treatment  and  stimulation  should 
be  begun  early. 


a3iT  •« 


CHAPTER  XII. 

DISEASES  OF  THE  DIGESTIVE  SYSTEM. 
DISEASES  OF  THE  LIPS. 
Ulcerations  at  Angle  of  Mouth. 

Synonym. — Perlech  e. 

Definition. — This  is  a  form  of  cracking  of  the  mucous  mem- 
brane or  ulceration  at  the  angle  of  the  mouth,  first  described 
by  Lemaistre. 

Etiology. — It  begins  as  a  small  fissure  or  crack  at  the  corner 
of  the  mouth,  which  becomes  infected  by  frequent  rubbing  and 
touching  by  the  tongue,  and  remains  at  this  point  entirely.  It 
is  more  frequently  seen  in  marasmic  and  anemic  children. 

Symptoms. — The  erosions  are  generally  linear  in  shape,  con- 
fined to  both  corners  of  the  mouth,  are  slightly  elevated  with  a 
red  and  indurated  base.  It  is  painful  if  the  child  opens  its 
mouth  wide,  as  when  yawning.  They  may  be  mistaken  for  the 
rhagades  of  syphilis,  but  no  mucous  patches  are  found  in  the 
mouth  in  perleche. 

Treatment. — The  course  of  perleche  is  usually  for  two  or  three 
weeks.  It  can  be  helped  by  applying  a  5  or  10  per  cent  solution 
of  nitrate  of  silver  direct  to  the  surface,  followed  by  a  drying 
powder,  as  zinc  oxide  or  bismuth.  The  application  of  an  oint- 
ment to  these  areas  prevents  the  encrustation  over  them ;  bismuth, 
gr.  X,  to  vaseline,  3i ;  3  per  cent  resorcin  ointment ;  benzoinated 
oxide  of  zinc ;  yellow  or  red  oxide  of  mercury,  are  efficient.  The 
use  of  the  ointment  following  the  silver,  in  winter,  is  specially 
desirable. 

DISEASES  OF  THE  TONGUE. 

Epithelial  Desquamation. 

This  condition  is  also  known  as  the  geographical  tongue.  There 
is  an  abrasion  or  exfoliation  of  the  epithelium  in  irregular  areas 

233 


234  THE   DISEASES   OP    CHILDREN. 

over  the  surface  of  the  tongue  with  normal  or  slightly-coated 
surface  between.  The  areas  are  slightly  elevated,  and  when 
freely  desquamated  leave  a  red  base.  It  occurs  frequently  in 
bottle-fed  infants  and  causes  no  discomfort;  as  a  rule  requires 
no  treatment  other  than  cleansing  washes  of  boracic  acid  solu- 
tion. 

DISEASES  OF  THE  MOUTH. 

Bednar's  Aphthae. 

Pathology. — This  is  a  symmetrical  ulceration,  one  on  each  side 
of  the  median  line  of  the  soft  palate  at  its  juncture  with  the  hard 
palate.  It  is  most  frequently  seen  in  the  new-born  or  infant 
under  six  months  of  age. 

Etiology. — It  is  caused  by  the  finger  of  the  nurse  too  vigor- 
ously cleansing  the  mouth,  an  abrasion  of  the  mucous  membrane 
occurring  readily  at  the  attachment  of  the  soft  to  the  hard  palate, 
bacterial  invasion  taking  place  at  this  site.    It  may  follow  thrush. 

Symptoms. — The  child  probably  refuses  to  nurse  or  it  may 
nurse  for  a  few  moments,  stop  and  fret  on  account  of  the  pain. 
Inspection  of  the  mouth  with  tongue  held  down  reveals  two  sym- 
metrical, round  ulcers  at  the  point  indicated  above.  They  may 
have  a  greyish  surface,  slightly  elevated,  with  reddened  area  at 
its  base. 

Nitrate  of  silver  solution,  5  per  cent,  applied  directly  to  the 
surfaces,  once  daily,  and  the .  mouth  in  front  of  these  ulcers 
washed  after  each  nursing,  usually  will  cure  them  in  a  few  days. 

STOMATITIS. 

This  may  be  of  the  following  varieties:  Catarrhal,  herpetic  or 
aphthous  and  ulcerative. 

The  catarrhM  variety  is  caused  by  irritants;  trauma;  exces- 
sively-hot liquids  or  food,  or  secondary  to  exanthemata. 

There  is  an  intense  reddening  of  the  mucous  membrane,  and 
desquamation  of  the  epithelium  and  a  salivation. 

S3n]iptoms. — There  is  a  sensation  of  heat  and  pain  in  the 
mouth ;  profuse  salivation ;  child  will  not  nurse ;  is  fretful  and 
cries  a  great  deal,  may  be  vomiting;  enlargement  of  glands  sub- 


DISEASES  OF   THE   DIGESTIVE   SYSTEM.  235 

maxillary  and  at  angle  of  jaw;  sleeps  with  mouth  open.     The 
duration  in  robast  children  is  usually  only  a  few  days. 

Treatment. — But  little  is  required.  Antiseptic  mouth  washes ; 
crushed  ice.  If  no  food  is  taken  for  some  days  gavage  is  of 
service. 

HERPETIC   OR  APHTHOUS   STOMATITIS. 

Etiology. — Teething,  irritating  substances  in  the  mouth,  and 
as  a  complication  of  gastrointestinal  disorders,  pneumonia  and 
other  infectious  diseases. 

Pathology. — Small  vesicles  appear  on  the  mucous  membrane 
of  the  lips  and  cheek;  these  may  coalesce,  forming  large  ones. 
They  are  superficial  as  a  rule  and  associated  with  more  or  less 
general  hyperemia,  especially  of  the  area  of  mucous  membrane 
directly  about  the  bases. 

Symptoms. — The  presence  of  the  characteristic  vesicles  on  the 
lips,  cheek  or  palate;  salivation;  difficulty  in  nursing;  enlarged 
glands.      The  chief  difference  is  in  the  appearance  of  the  vesicles. 

Treatment. — Care  should  be  taken  in  using  an  antiseptic  or 
cleansing  wash,  not  to  rub  the  vesicles  so  as  to  leave  an  abraded 
surface  below.  Chlorate  of  potash,  2  or  3  grains,  well  diluted, 
to  a  child  of  tMo  years  is  of  great  benefit.  If  the  areas  coalesce 
and  leave  a  raw  base,  nitrate  of  silver  is  of  service,  in  a  5  per 
cent  solution.     Prophylaxis  is  most  important. 

ULCERATIVE  STOMATITIS. 

Etiology. — It  is  of  bacterial  origin,  may  follow  the  exanthe- 
mata, and  complicate  carious  teeth.  It  is  seen  in  wasting  dis- 
eases also. 

Pathology. — xVn  ulceration  which  usually  begins  at  the  base 
of  a  tooth  and  spreads  over  the  gum  to  the  mucous  membrane  of 
the  lips  and  cheeks.  The  ulcers  usually  have  a  whitish,  depressed 
surface  with  red  edges.  There  may  be  deep  ulceration  at  roots  of 
teeth  causing  them  to  loosen  and  fall  out. 

Symptoms. — Pain  when  chewing  is  attempted,  excessive  flow 
of  saliva,  fetid  breath,  tongue  thickly  coated,  ulcers  bleed  freely 
if  touched,  sordes  on  teeth,  child  is  fretful,  cries  a  great  deal 
and  sleeps  poorly.     There  may  be  a  slight  rise  of  temperature. 


236  THE   DISEASES   OF    CHILDREN". 

The  neighboring  lymphatic  glands  are  usually  enlarged.     The 
gangrenous  form  may  supervene. 

Treatment. — Weak  peroxide  of  hydrogen  solution  25  per  cent 
followed  by  an  antiseptic  wash;  saturated  boracic  acid  solution, 
full  strength,  Dobell's  solution,  or  solution  made  from  Seller's 
tablets.  The  internal  administration  of  potassium  chlorate  is 
almost  a  specific,  and  should  be  given  in  2  or  3  grain  doses  to 
a  child  of  two  years  every  3  or  4  hours.  The  local  application  of 
nitrate  of  silver  solution,  10  per  cent,  to  the  base  of  the  ulcers 
is  of  service. 

GANGRENOUS  STOMATITIS. 

Synonyms. — Noma;  cancarem  oris;  gangrene  of  cheek; 
Wangenbrand. 

This  is  a  sloughing  or  gangrenous  process  involving  the 
mucous  membrane  and  tissues  of  the  cheek,  as  a  rule,  though 
it  may  spread  to  the  gums  and  lips.  Sufficient  tissue  may  be 
involved  to  have  a  perforation  of  the  cheek.  Both  sides  of  the 
mouth  may  be  simultaneously  affected.  It  usually  occurs  be- 
tween two  and  six  years  of  age. 

Etiology. — No  specific  organism  has  been  satisfactorily  iso- 
lated in  these  cases,  though  two  Russian  observers  claim  to 
have  isolated  a  small  bacillus  and  produced  the  same  conditions 
in  guinea-pigs.  The  diphtheria  bacillus,  strepto-  and  staphylo- 
cocci, have  been  found.  Noma  occurs  after  the  exanthemata, 
and  diphtheria,  after  any  wasting  or  prolonged  disease  in  which 
resistance  is  low,  and  may  start  from  a  severe  ulcerative 
stomatitis.     It  may  be  epidemic  in  institutions. 

Pathology. — The  starting  point  is  usually  on  the  gum  near  the 
teeth,  and  this  quickly  spreads  to  the  mucous  membrane  of  the 
cheek.  The  area  involved  is  more  or  less  symmetrically  round, 
and  at  first  can  be  felt  as  a  small,  hardened  mass  which  soon 
breaks  down,  leaving  a  dark,  angry-looking  area,  bathed  in  pus, 
and  from  which  a  foul  odor  emanates.  In  some  favorable 
cases  a  mass  of  tissue  separates  and  falls  out,  leaving  an  excava- 
tion covered  with  granulation  tissue. 

Symptoms. — At  first  there  are  few  general  symptoms,  but  soon 
there  is  fever  to  103°  or  104°  F. ;  great  restlessnass ;  pain;  in- 


DISEASES  OP   THE   DIGESTIVE  SYSTEM.  237 

ability  to  chew  or  swallow;  fetid  breath,  which  is  noticeable  as 
soon  as  the  room  is  entered;  the  cheek  is  much  swollen  and 
indurated,  the  edema  spreading  to  the  upper  and  lower  eye- 
lids; the  skin  of  the  cheek  assumes  a  dusky,  dull  red  color. 
The  neighboring  glands  quickly  enlarge. 

In  a  few  hours  the  slough  has  extended,  and  in  one  to  five 
days  unless  the  process  is  arrested,  the  cheek  will  probably  be 
perforated.  At  the  same  time  the  gangrene  may  extend  to  the 
lower  or  upper  jaw,  involving  the  bone  and  causing  the  teeth 
to  loosen  and  drop  out.  Q'here  is  a  septic  diarrhea,  and  at  this 
stage  great  prostration  with  rapid  and  feeble  pulse. 

Prognosis. — The  prognosis  is  grave,  fully  75  per  cent  suc- 
cumb in  spite  of  treatment.  The  duration  is  from  one  to  three 
weeks,  and  death  ensues  from  either  toxemia  or  broncho- 
pneumonia.     Usually  severe  deformities  of  the  face  remain. 

Treatment. — Attention  should  always  be  given  to  stomatitis 
of  any  form,  especially  the  ulcerative  variety,  to  prevent  the 
engrafting  of  a  canearem  oris  upon  it.  As  soon  as  the  diagnosis 
has  been  made,  under  a  general  anesthesia,  the  area  involved 
.should  be  thoroughly  cleansed  and  cauterized  with  the  fine  tip 
of  a  Paquelin  cautery,  and  the  cauterization  should  extend  be- 
yond the  diseased  area.  I  have  had  one  case  recover  treated  in 
this  manner  without  perforation  of  the  cheek,  but  ulceration 
extending  very  close  to  the  skin. 

In  this  case  an  examination  of  scrapings  from  the  ulcer  re- 
vealed no  organisms  except  the  pus-producing  ones. 

Loose  teeth  and  spiculsB  of  bone  should  be  removed. 

The  diseased  area  .should  be  touched  each  day  with  a  20  per 
cent  nitrate  of  silver  solution,  and  a  cleansing  antiseptic  mouth- 
wash used. 

It  is  wise  to  have  a  culture  made  from  scrapings  from  the 
mass,  and  the  diphtheria  bacillus  looked  for.  If  isolated,  the 
child  should  be  given  a  dose  of  diphtheria  antitoxin  at  once. 

Active  supportive  and  stimulating  treatment  mu.st  be  used, 
such  concentrated  nourishment  as  beef  juice  and  broth,  pep- 
tonized milk,  egg-nogg,  etc. 


238  THE   DISEASES   OF    CHILDREN. 

THRUSH. 

Synonyms. — Sprue,  muguet,  soor,  parasitic  stomatitis. 

This  is  an  affection  of  the  mucous  membrane  due  to  the  growth 
upon  it  of  a  specific  organism,  the  saccliaromyces  albicans. 

Etiology. — The  saccharomyces  albicans  and  not  the  oidium 
albicans  is  the  cause  of  the  condition.  Examination  of  the 
deposit  shows  the  white  threads  or  mycelium  and  the  small, 
oval  bodies,  the  spores.  It  is  usually  limited  to  the  mucous 
membrane  of  the  mouth,  but  may  spread  to  the  larynx,  esoph- 
agus and  stomach.  The  organism  is  carried  to  the  mouth,  either 
upon  the  ordinary  nursing  paraphernalia  or  the  rubber  nipple 
("persuader"  or  "comforter")  toys,  sugar-teats,  etc.  Poorly 
nourished  children  are  prone  to  develop  it. 

Symptoms. — Upon  the  tongue,  gums  and  mucous  membrane 
of  the  lips,  later  of  the  cheeks,  there  is  a  white  deposit  varying 
in  size  from  a  pin  point  to  an  area  the  size  of  the  little  finger 
nail,  the  larger  masses  resembling  a  mass  of  curds.  Patches 
may  be  found  here  and  there,  or  may  be  very  numerous.  There 
is  apt  to  be  a  coincident  gastrointestinal  involvement,  and  the 
whole  area  of  buccal  mucous  membrane  is  hot,  red  and  dry. 
The  child  refuses  to  nurse,  or  if  older  its  bottle  or  ordinary 
food  is  pushed  aside. 

This  condition  is  due,  as  a  rule,  to  neglect  or  to  over-zealous 
cleansing  of  the  mouth,  resulting  in  an  abrasion  in  which  be- 
comas  engrafted  the  infective  organism. 

Treatment. — The  best  treatment  is  prophylaxis.  It  can  be 
prevented  by  careful  attention  to  details  of  cleanliness,  of  both 
baby  and  nursing  paraphernalia  and  breasts  and  nipples  of 
mother.  Nursing  infants  are  less  apt  to  develop  sprue  than 
older  ones.  The  occurrence  of  sprue  is  usually  an  indication 
that  the  nurse  or  person  in  charge  is  careless  about  the  toilet 
of  the  mouth  before  and  after  nursing,  and  of  the  bottles  and 
nipples. 

Saturated  solution  of  boracic  acid  is  an  efficient  remedy  and 
preventive  as  well.  The  finger  wrapped  in  absorbent  cotton 
is  wet  with  the  boracic  acid  solution  and  the  deposit  gently 
removed. 

This  must  be  done  very  gently  at  all  times,  as  the  mucous 


DISEASES  OF    THE   DIGESTIVE   SYSTEM.  239 

membrane  is  very  easily  abraded.  The  cotton  is  best  changed 
as  one  part  is  cleansed.  If  an  aphthous  or  ulcerated  spot  is 
found  it  should  be  touched  with  a  nitrate  of  silver  solution. 
A  cure  is  generally  had  at  the  end  of  a  week  or  so. 

GONORRHEAL  INFECTION  OF  THE  MOUTH. 

This  is  generally  associated  with  an  acute  infection  in  the 
mother  of  a  similar  nature,  urethral,  vulvovaginal,  conjunctival, 
and  is  due  to  the  specific  organism,  the  gonococcus  of  Neisser 
being  transferred  to  the  child's  mouth.  There  must  first  be  a 
trauma,  not  necessarily  macroscopic  in  size.  It  occurs  usually 
before  the  child  is  two  weeks  old.  Fortunately  this  is  a  rare 
infection,  but  few  cases  having  been  reported. 

Symptoms. — These  may  be  very  few,  and  it  is  entirely  pos- 
sible for  the  condition  to  go  entirely  unrecognized.  It  may 
become  engrafted  upon  a  Bednar's  aphthaB  or  an  abrasion  of 
tlie  mucous  membrane  due  to  cleansing  the  mouth.  The  swelling 
and  appearance  of  the  mucous  membrane  is  like  that  seen  in 
catarrhal  stomatitis,  and  to  be  recognized  scrapings  from  the 
mucous  membrane  must  be  examined  microscopically.  There 
is  but  little  discharge.     It  usually  runs  a  short  course. 

Treatment. — Cleanliness,  frequent  washing  with  boracic  acid 
solution,  and  twice  daily  swabbing  out  the  entire  buccal  mucous 
membrane,  especially  under  the  tongue  and  lips  and  gums  with 
a  2  per  cent  nitrate  of  silver  solution,  or  the  same  strength  solu- 
tion of  protargol. 

Care  must  be  taken  to  protect  the  eyes  and  thumb-sucking 
must  be  prevented. 

SYPHILITIC  STOMATITIS. 

When  snuffles  in  a  new-born  child  is  seen  the  motith  should 
be  carefully  searched  for  possible  mucous  patches. 

Any  case  in  which  ulcers  are  found  upon  the  buccal  mucous 
membrane  should  be  looked  upon  with  suspicion. 

Typical  mucous  patches  are  not  as  deep  as  the  ulcers  of  non- 
specific ulcerative  stomatitis,  are  usually  upon  the  lips  or  mu- 
cous membrane  of  cheeks,  and  more  rarely  on  the  gums.  They 
have  a  dull,  white  base  and  may  be  bathed  in  a  thin  pus  secre- 


240  THE   DISEASES   OF    CHILDREN. 

tion.     They  may  be  associated  with  fissures  at  the  corners  of 
the  mouth. 

Local  application  of  a  mild  antiseptic  wash,  with  vigorous 
antisyphilitic  treatment  is  indicated. 

RANULA. 

This  is  a  cystic  formation  under  the  tongue,  on  either  side  of 
the  frenum,  and  is  due  to  an  occlusion  of  one  of  the  salivary 
ducts  or  a  duct  from  one  of  the  mucous  glands,  a  Bland-Nuhn 
or  Rivinian  Gland.  There  may  be*  a  lodgement  of  a  small  cal- 
culus in  the  duct,  closing  it. 

Symptoms. — When  the  tongue  is  raised  a  small,  soft,  fluctu- 
ating tumor  is  found  under  the  tongue.  The  calculus  may  be 
felt  if  present.  These  may  be  of  such  size  as  to  interfere  with 
nursing  and  with  swallowing,  even  with  the  closure  of  the 
mouth. 

Treatment. — Incision  of  the  cysts,  the  child  being  held  on 
the  nurse's  lap,  head  between  physician's  knees,  who  sits  facing 
the  nurse.  The  tongue  can  be  held  out  of  the  way  by  means 
of  the  handle  of  a  grooved  director. 

Saliva  or  a  viscid  mucus  may  escape  on  incision  of  the  cyst. 

TONGUE-TIE. 

Every  new-born  baby's  mouth  should  be  examined,  and  the 
frenum  of  the  tongue  especially  inspected.  If  a  baby  cannot 
protrude  its  tongue  between  or  at  least  to  its  lips,  the  frenum 
is  too  short,  the  tip  folding  on  itself,  making  it  difficult  to  form 
a  vacuum  and  the  nursing  is  interfered  with.  This  is  seen  com- 
paratively infrequently,  and  when  clipped  causes  great  relief. 

Treatment. — The  child  is  held  as  described  in  the  treatment 
of  ranula,  and  the  tongue  held  by  the  handle  end  of  a  grooved 
director,  the  frenum  projecting  through  the  slit  in  this.  It  is 
then  cut  with  a  pair  of  blunt-pointed  scissors  which,  have  been 
previously  set  so  as  to  make  the  cut  of  prescribed  depth,  and  if 
this  does  not  liberate  the  tongue  sufficiently  it  is  torn  by  the 
finger  as  needed.     The  bleeding  is  usually  very  slight. 

RIGA'S  DISEASE. 

This    condition,    described    by   Dr.    Guiseppe,i    occurs    more 


1  Gazz.   Degli   ospedali-dello   clin.,    No.    153,    1907. 


DISEASES  OF    THE   DIGESTIVE   SYSTEM.  241 

frequently  in  Southern  Italy,  and  is  mentioned  because  of  its 
likeness  to  more  benign  conditions  occurring  in  this  country 
just  described.  It  was  first  exhaustively  studied  by  Riga  in 
1880.  It  does  not  occur  epidemically.  The  etiology  is  very 
obscure. 

Symptoms. — It  usually  occurs  in  vigorous  and  previously 
healthy  children  during  the  first  six  months  of  life.  An  ulcer 
or  granuloma  forms  at  the  side  of  the  frenum  of  the  tongue, 
dirty  gray  in  color.  The  child  falls  suddenly  ill  with  the  ap- 
pearance of  the  ulcer,  suffers  with  severe  collapse  and  soon 
dies. 

The  treatment  is  of  no  avail. 

ALVEOLAR  ABSCESS. 

This  is  an  infection  of  the  gum  or  the  alveolar  process,  orig- 
inating usually  in  a  tooth.  The  conditions  may  result  in  an 
abscess  which  will  discharge  within  the  mouth,  but  it  is  not 
at  all  uncommon  for  them  to  open  externally,  through  the  cheek, 
at  the  angle  of  the  jaw  or  below  the  chin. 

Symptoms. — Usually  there  is  a  period  during  which  the  child 
complains  of  toothache,  and  an  examination  of  the  mouth  may 
reveal  a  cavity  which  is  filled  with  food  particles.  After  the 
subsidence  of  the  pain  the  swelling  begins  and  this  is  apt  to  be 
painless,  or  nearly  so. 

The  swelling  is  firm  and  tense  with  some  redness  of  the  skin. 
The  mueou.s  membrane  of  the  affected  side  is  edematous.  Pus 
usually  is  found  and  frequently  can  be  pressed  out  from  the 
gum  along  the  tooth. 

Treatment. — ]\Iuch  more  care  should  be  given  the  teeth  of 
children  than  is  usually  the  case.  Too  frequently  their  cleans- 
ing is  left  entirely  to  the  child  and  not  supervised,  food  collects 
and  an  infected  gum  results.  Children  should  be  taken  to  a 
dentist  at  least  twice  a  year,  the  teeth  carefully  inspected,  and 
attention  given  those  which  show  signs  of  softening  or  breaking 
down. 

When  an  abscess  forms  it  should  not  be  allowed  to  rupture 
outside  but  opened  on  the  inside  of  the  mouth.  It  should  then 
be  treated  as  any  other  abscess  and  free  dainage  maintained. 


242  THE   DIStiASES   OF    CHlLDRE>r. 

Regular  inspection  of  the  mouths  of  school  children  should  be 
insisted  upon  by  all  school  boards. 

FISTULA  OF  NECK  (BRANCHIAL  FISTULA). 

A  branchial  fistula  is  a  congenital  failure  of  the  second  and 
third  branchial  clefts  to  close.  An  opening  persists  in  the  neck 
ending  at  the  inner  side  of  the  sternocleido  mastoid  muscle, 
near  the  sternoclavicular  joint.  One  or  both  sides  may  be 
affected;  if  one,  it  is  usually  the  left. 

The  tract  may  end  in  a  blind  pouch  but  usually  leads  in  a 
more  or  less  straight  course  to  the  esophagus  or  pharynx.  If 
the  external  opening  closes  a  cyst  usually  forms  rapidly,  it  being 
called  a  hranchial  cyst.  The  contents  of  these  cysts  vary,  in 
different  cases.  They  may  contain  mucus,  serum,  serum  and 
blood  and  epithelium. 

Treatment. — The  treatment  of  both  conditions  is  entirely 
surgical. 

ACUTE  ESOPHAGITIS. 

An  acute  inflammation  of  the  esophagus  which  usuallj^  is 
caused  by  the  passage  of  a  foreign  body,  the  swallowing  of  a 
caustic  as  a  lye  solution  or  acid,  or  ammonia.  It  may  follow 
an  acute  inflammation  of  the  mouth  and  pharynx,  as  in  diph- 
theria or  thrush. 

Symptoms. — The  severity  of  the  symptoms  depends  entirely 
upon  the  strength  of  the  irritating  substance  swallowed  and 
the  severity  of  the  inflammation,  if  it  is  an  extension  from 
above.  In  all  cases  there  is  great  and  continuous  pain,  dys- 
phagia, retching,  perhaps  vomiting,  which  greatly  increases  the 
pain. 

The  vomitus  may  contain  pus  and  usually  some  blood.  There 
is  a  greatly  increased  flow  of  saliva.  Restlessness  is  a  marked 
symptom. 

There  is  a  swelling  of  the  mucous  membrane  of  the  mouth 
and  pharynx,  and  if  this  is  very  great  there  may  be  considerable 
dyspnea  following  the  swallowing  of  the  irritant. 

The  sequel  in  thase  cases  which  is  most  to  be  feared  is  a 
stricture  of  the  esophagus.     A  spasmodic  stricture  may  apjiear 


DISEASES  OP   THE  DIGESTIVE  SYSTEM.  243 

as  early  as  the  second  day,  the  cicatricial  stricture  at  a  later 
date,  after  a  week  or  two,  or  it  may  be  delayed  several  weeks. 

Treatment. — The  treatment  of  the  cases  after  the  injury  is 
medical.  Morphia  or  codeine  in  appropriate  dosage  to  control 
the  muscular  spasm  and  pain ;  hypodermic  stimulation  is  needed ; 
no  food  or  water  by  the  mouth;  sustain  the  child  by  nutrient 
enemata;  cold  applications  externally  to  neck.  As  soon  as  it  is 
certain  that  an  esophageal  stricture  is  present,  evidenced  by  a 
muscular  spasm  on  swallowing  and  regurgitation  at  once,  or 
entire  inability  to  swallow  solid  food  and  difficulty  in  swallowing 
liquids;  under  a  general  anesthetic  chloroform  or  gas  and  oxy- 
gen, the  esophagus  should  be  carefully  explored  by  esophageal 
bougies,  olive-tipped,  to  locate  the  number  and  location  of  the 
strictures.  Makenzie  has  stated  the  distance  in  a  child  of  about 
two  years  from  the  gmns  to  the  cardiac  orifice  to  be  about  7 
inches.  The  location  of  the  strictures  accomplished,  their  size 
should  be  ascertained  by  passage  of  progressively  larger  bougies, 
and  this  repeated  at  intervals  of  three  or  four  days. 

With  an  impassable  stricture  the  case  becomes  surgical  and 
may  eventuate  in  a  gastrotomy. 

STENOSIS  OF  THE  PYLORUS. 

Pathology. — Our  knowledge  of  pyloric  stenosis  is  directly  the 
result  of  postmortem  investigations.  A  pyloric  tumor  is  almost 
uniformly  found  about  the  size  of  the  end  of  the  thumb.  It  is 
free  from  adhesions,  oval  in  shape,  firm,  hard  and  smooth.  It 
is  located  at  the  pylorus  and  when  present  makes  easy  the  loca- 
tion of  the  pylorus,  which  is  difficult  ordinarily. 

Microscopically  there  is  found  a  hyperplasia  of  the  circular 
muscular  fibers,  and  a  very  great  hypertrophy  of  the  folds  of  the 
mucous  membrane,  which  lie  longitudinally.  Secondary  changes 
occur  in  the  stomach,  namely  a  dilatation  and  thinning  of  its 
walls,  which  are  covered  with  a  thick  mucus. 

S3nnptoms. — The  child  is  apparently  normal  when  born.  No 
symptoms  are  present,  as  a  rule,  until  the  third  or  fourth  day, 
when  the  first  noticed  will  probably  be  vomiting.  There  is  a 
disinclination  to  nurse.     The  vomiting  may  be  delayed  as  late 


244  THE  DISEASES  OP   CHILDREN. 

as  the  end  of  the  second  week.  The  vomiting  is  characteristic, 
being  expulsive,  violent  and  persistent.  One  or  two  nursings 
may  be  retained,  and  then  the  total  swallowed  is  violently 
ejected.  The  child  is  nearly  always  restless  and  uncomfortable 
after  nursing  and  apparently  relieved  only  by  vomiting.  No 
nausea  is  present. 

Examination  of  the  vomitus  may  show  free  hydrochloric  acid, 
but  it  is  not  increased  in  amount ;  usually  there  is  no  bile 
present,  no  blood  or  lactic  acid. 

There  is  obstinate  constipation,  and  what  is  passed  for  a 
number  of  days  continues  to  be  like  meconium  in  appearance. 

The  child  instead  of  gaining  its  second  week  continues  to 
lose  in  weight.  The  temperature  is  below  normal  and  the  pulse 
fast,  out  of  proportion. 

Examination  of  the  abdomen  may  reveal  a  fairly  character- 
istic condition ;  a  distension  of  the  abdomen  above  the  umbilicus, 
and  a  wave  of  peristalsis  may  be  seen  moving  from  left  to  right. 
This  is  best  seen  in  a  good  light  after  a  feeding.  Below  the 
umbilicus  the  abdomen  is  collapsed  and  concave.  Palpation 
may  reveal  a  pyloric  tumor  one-half  inch  to  the  right  and  three- 
fourths  of  an  inch  above  the  umbilicus. 

The   tongue  is  clean  and  the  breath  normal. 

Diagnosis  is  principally  from  gastric  indigestion  and  pyloric 
spasm.  In  the  first  the  vomiting  does  not  occur  as  regularly, 
and  the  amount  vomited  is  not  so  large  or  as  expulsive  as  in 
stenosis.  The  bowels,  after  a  few  days  of  gastric  indigestion,  are 
apt  to  be  loose  and  contain  mucus,  and  the  loss  in  weight  is  not 
so  rapid.  No  peristaltic  wave  is  seen  in  indigestion.  In  pyloric 
spasm,  the  symptoms  are  essentially  the  same,  but  there  is  no 
tumor  present  except  in  hypertrophic  stenosis. 

Prognosis. — This  depends  entirely  upon  the  early  recognition 
of  the  condition  and  the  promptness  of  surgical  intervention. 
The  mortality  following  operation  is  high.  Of  135  eases  col- 
lected by  Scudder  ^  the  mortality  was  48.8  per  cent.  He  esti- 
mates the  mortality  of  medically-treated  cases  as  between  80 
and  90  per  cent. 

Treatment. — This  is  essentially  surgical.     An  operation  should 


'Scudder:      Canadian    Practitioner,   August,    1908,   p.   95. 


DISEASES   OF    THE   DIGESTIVE   SYSTEM.  245 

be  performed  immediately  the  diagnosis  is  made.  Scudder 
mentions  three  operations:  The  Loreta  operation,  consisting 
in  opening  the  stomach  and  stretching  the  pylorus  by  a  pair 
of  forceps  introduced  through  this  opening.  Second,  pyloro- 
plasty and  incision  from  the  stomach  into  the  duodenum,  across 
the  pyloric  tumor,  and  suturing  this  incision  so  as  to  increase 
the  lumen  of  the  pylorus.  Both  these  methods  he  discredits  as 
dangerous  and  unsatisfactory.  Posterior  gastroenterostomy  is 
recommended  after  the  Mayo  method.  Several  times  before  the 
operation  it  is  advised  to  give  an  enema  of  brandy  and  salt  solu- 
tion. Stomach  washing  just  before  the  operation.  Arms  and 
legs  confined  to  body  with  separate  sheets.  Median  incision  to 
left  of  umbilicus.  Layer  suture  of  wall  after  operation  will 
lessen  possibility  of  hernia. 

The  after  treatment  is  important,  the  Fowler  position ;  very 
careful  feeding  of  whey  or  barley  water  or  breast  milk  diluted, 
10  or  12  hours  after  the  operation,  first,  a  teaspoonful,  grad- 
ually increased  to  a  tablespoonful  every  three  hours.  Breast 
milk  should  be  substituted  as  soon  as  possible. 

Vomiting  may  occur  two  or  three  times  a  day  after  the  opera- 
tion, but  gradually  subsides. 

DISEASES  OF  THE  STOMACH  AND  INTESTINES. 

General  Considerations. — The  digestion  of  infants  and  children 
is  essentially  different  from  an  adult.  The  new-born  infant's 
stomach  is  a  dilated  end  of  the  esophagus,  without  much  shape, 
but  it  quickly  assumes,  however,  the  shape  of  the  adult  stomach. 
Saliva  is  secreted  in  very  small  quantities  until  after  the  erup- 
tion of  the  deciduous  teeth.  The  stomach  of  the  infant  fed  upon 
mother 's  milk  should  empty  itself  in  two  hours,  a  slightly  longer 
period  being  taken  in  the  stomach  preparation  of  cow's  milk 
for  digestion  and  absorption.  At  rest  the  stomach  contains 
mucus  and  but  little  acid,  in  the  presence  of  milk,  hydrochloric 
acid  is  secreted.  Lactic  acid  is  found  occasionally,  not  always. 
Free  hydrochloric  acid  is  not  found  immediately  after  a  nursing, 
but  in  from  one  to  two  hours  following. 

The  principal  duty  of  the  stomach  in  digestion  is  the  precipi- 
tation of  the  casein,  the  proteid  in  mother's  milk  coagulating 


246  THE   DISEASES   OP    CHILDREN. 

in  small  flocculi,  that  of  cow's  milk  in  larger  masses.  The  rennet 
ferment  or  labferment  is  the  coagulating  .agent.  From  the 
stomach  the  contents  pass  into  the  duodenum  where  digestion 
proceeds,  aided  by  the  pancreatic  juices.  Here  the  carbo- 
hydrates, peptones  and  fats  are  digested  and  absorbed,  the  pan- 
creatic ferments  being  trypsin,  steapsin  and  ptyalin.  The  bile 
aids  in  the  emulsifying  of  the  fats.  The  digestion  of  fat  is  a 
problem  which  is  as  yet  not  fully  understood,  but  it  is  a  fact 
that  fat  causes  much  more  trouble  than  is  usually  believed. 

The  bacteria  of  the  stomach  and  intestines  are  not  fully  inves- 
tigated, especially  of  the  former.  The  principal  bacteria  which 
may  be  found  in  the  stomach  are  the  hacterium  lactis  arogenes, 
hacillus  coli  communis,  sarcini  ventriculi,  the  hay  tacillus, 
and  other  non-pathogenic  organisms. 

The  Shiga  hacillus,  belonging  to  colon  typhoid  group,  has 
been  found  in  the  intestinal  discharges  in  certain  cases  of  diar- 
rhea, especially  in  those  in  which  the  discharge  of  mucus  and 
blood  is  present.  Further  study  may  reveal  much  of  the  life 
history  of  this  organism,  both  in  and  out  of  the  intestinal  tract. 
Among  the  others  most  frequently  found  are  the  hacillus  coli 
communis,  streptococci,  staphylococci,  the  hacillus  lactis  cero- 
genes  and  the  hacillus  suhtilis. 

The  numher  of  stools  in  the  24  hours  varies  greatly  in  differ- 
ent babies,  the  character,  consistence  and  color  of  the  passage 
being  an  indication  of  whether  a  comparatively  large  number 
is  within  the  range  of  normal.  The  nursing  infant  during  the 
first  few  weeks  may  have  from  three  to  four  movements  in  the 
24  hours,  after  this  period  they  are  less  frequent,  but  at  least 
one  passage  should  be  had  in  24  hours,  and  under  no  condition 
should  this  be  varied  from. 

The  number  and  character  of  the  bacteria  in  milk  bear  a 
certain  relation  to  this  phase  of  the  subject.  It  is  well  known 
that  ordinary  market  milk  contains  from  300,000  to  several 
million  bacteria  to  the  cubic  centimeter,  and  it  has  been  re- 
peatedly shown  that  such  milk  fed  to  infants  results  directly 
in  serious  digestive  disturbances  and  frequently  in  severe  toxic 
and  inflammatory  conditions  of  the  stomach  and  intestines. 


DISEASES   OP    THE   DIGESTIVE   SYSTEM.  247 

The  Feces. — The  feces  of  the  new-born  are  thick,  black,  tarry- 
like  and  tenacious,  called  meconium.  These  characteristic  move- 
ments give  way  to  the  normal  stool  of  the  infant.  These  are 
yellow,  smooth,  consistent  and  mush-like,  as  soon  as  the  moth- 
er's milk  is  secreted  or  when  milk  is  fed  artificially,  the  black 
color  being  gradually  replaced  by  the  yellow  -toward  the  third 
or  fourth  day.  The  mother 's  milk  varies  so  in  its  analysis  at 
different  times  of  the  day  and  night  that  the  infant's  stools  may 
vary  greatly  in  24  hours.  They  may  vary  from  a  bright  yellow 
to  a  decided  greenish  color,  and  may  contain  minute  or  larger- 
sized  masses,  whitish  in  color. 

These  masses  may  be  composed  entirely  of  casein,  in  which 
case  they  are  firm  and  hard,  or  of  fat,  when  they  are  soft  and 
smooth.  If  they  are  fat  masses  they  may  have  a  casein  center 
or  bacteria  may  form  the  nucleus.  The  recognition  of  the  char- 
acter of  the  "curd"  in  a  movement  is  of  importance  in  arti- 
ficially-fed infants.  The  stools  of  artificially-fed  infants,  as  a 
rule,  are  larger  in  amount  and  lighter  in  color.  The  effect  of 
carbohydrate  diluent  in  milk  is  shown  in  the  stools  by  the  curds 
being  softer  and  smaller  than  when  water  is  used  as  the  diluent. 

Thin,  yellow,  acid  movement,  containing  fine  white,  curd  like 
masses  which  are  soft  and  easily  spread  when  pressed  upon — too 
much  fat. 

Large,  bean-like,  firm  masses,  with  discolored,  shiny  capsule — 
casein  in  excess. 

^lucus,  thick  and  tenacious,  in  large  quantities — inflammation 
of  sigmoid  or  colon.  When  green  discoloration  is  present  with 
acid  reaction  of  stool  there  is  serious  disagreement  of  the  food. 

Foamy,   acid  stool — too  much  sugar. 

The  reaction  of  the  infant's  stools  fed  on  breast  milk  is  usually 
acid,  when  fed  on  cow's  milk  is  either  neutral  or  alkaline. 

The  odor  of  the  normal  breast-fed  infant's  stool  is  acid,  while 
that  of  the  artificially  fed  has  the  odor  of  decomposition.  This 
is  especially  so  when  animal  broths  are  ingested. 

The  bacterial  flora  of  the  infant's  intestine  has  been  the  sub- 
ject of  interesting  study  by  a  number  of  observers,  but  is  of  no 
clinical  value  as  yet. 


248  THE   DISEASES   OF    CHILDREN. 

GASTRIC  DISORDERS. 

Disorders  of  the  stomach  may  he.  functional  or  organic  or 
reflex.  One  of  the  principal  symptoms  of  disorders  of  the 
stomach  is  vomiting.  The  natural  position,  shape  and  size  of 
the  infant's  stomach  makes  vomiting  very  easy.  It  may  be  only 
a  regurgitation  of  the  food  as  it  has  been  ingested,  or  the  entire 
contents  may  be  expelled,  occurring  at  different  periods  after 
feeding.  Among  the  causes  are  too-rapid  feeding,  impure  milk 
in  the  artificially  fed,  changes  in  the  mother 's  milk  from  various 
causes,  pyloric  or  intestinal  obstruction,  ulceration  of  the  stom- 
ach, cyclic,  recurrent  or  periodic  vomiting,  and  that  caused  by 
the  acute  infectious  and  exanthematous  diseases. 

ACUTE  GASTRIC  INDIGESTION. 

Synonyms. — Acute  gastric  catarrh.    Acute  dyspepsia. 

Acute  gastritis,  that  caused  by  the  swallowing  of  caustic  or 
corroding  substances,  is  rarely  seen  in  infants,,  and  its  symptoma- 
tology is  practically  that  of  acute  indigestion. 

Etiology. — The  most  frequent  causes  of  an  acute  indigestion 
are  irregular  and  over  feeding.  Changes  in  the  character  of 
the  milk  may  cause  it;  as  a  single  cow's-milk  feeding  substituted 
for  a  breast  feeding;  changes  in  character  of  the  breast  milk 
from  nervous  excitement,  fear,  anger,  etc. ;  over  indulgence  in 
older  children  at  children's  parties;  pastries;  hurried  eating 
and  improper  mastication,  as  is  the  case  when  carious  teeth  are 
present ;  sudden  changes  in  temperature ;  violent  exercise  after 
eating ;'  too  early  bathing  after  a  meal,  etc. 

Predisposing  causes  are  a  prolongation  of  any  one  of  the 
active  causes  mentioned,  as  irregular  feeding  and  eating  between 
meals,  frequent  indulgence  in  sweets  and  any  condition  which 
lowers  vitality. 

Pathology. — No  specific  lesions  are  present,  the  condition 
being  functional,  an  arrest  of  secretion  most  likely,  as  well  as 
muscular  action. 

Symptoms. — The  first  symptom  may  be  languor  and  lassitude ; 
the  child,  if  older,  will  lie  down  in  preference  to  playing,  and 
if  old  enough  may  complain  of  headache.  Pain  referred  high  up 
in  the  abdomen  may  be  present,  followed  by  nausea,  vomiting 


DISEASES  OF    THE   DIGESTIVE  SYSTEM.  249 

and  retching.  The  vomited  matter  shows  food  as  it  was  swal- 
lowed, perhaps  some  hours  before,  and  is  apt  to  be  sour. 

There  is  always  a  rise  in  temperature,  it  may  be  slight,  but  is 
usually  between  102°  and  104°  F. ;  the  pulse  is  rapid,  with 
slight  increase  in  the  number  of  respirations.  There  is  much 
prostration,  languor  and  deep  sleep  after  the  cessation  of  the 
vomiting.  I  have  seen  repeated  convulsions  until  the  stomach 
was  completely  emptied.  I  recall  one  child  which  had  a  number 
of  severe  general  convulsions  at  intervals  for  several  hours,  which 
ceased  only  after  the  stomach  was  entirely  cleared  out.  The 
movements  are  apt  to  be  abnormal,  containing  undigested  food 
and  showing  signs  of  fermentation,  are  frequent,  and  accom- 
panied with  gas  and  straining.  The  nausea  may  continue  some 
hours  after  the  cessation  of  the  active  vomiting. 

Prognosis. — This  is  usually  good  as  soon  as  the  stomach  and 
intestines  are  thoroughly  cleared  out  of  all  undigested  and  irri- 
tating substances.  In  neglected  cases,  or  those  fed  too  soon 
after  an  attack,  there  develops  a  severe  condition  of  the  bowel 
which  may  result  fatally.  The  younger  the  child  the  more 
severe  the  toxemia. 

Diagnosis. — This  is  not  always  easy.  It  may  be  difficult  to 
rule  out  the  beginning  of  one  of  the  exanthemata,  which  may 
be  determined  only  by  the  appearance  of  the  rash,  or  a  pneu- 
monia, by  the  development  of  the  pathognomonic  physical  signs. 

Treatment. — The  first  indication  is  to  empty  the  stomach.  In 
an  older  child  this  may  be  facilitated  by  causing  it  to  swallow 
a  glass  or  so  of  water,  cool  or  warm,  this  being  ejected  at  once 
brings  with  it  much  offending  material.  If  this  is  not  possible 
the  stomach  should  be  washed.  This  is  accomplished  by  a  soft 
rubber  catheter.  No.  16,  American,  which  is  attached  to  rubber 
tube  by  a  glass  tube,  with  a  funnel  at  the  free  end.  The 
catheter  is  passed  into  the  stomach,  the  child  being  held  in  the 
upright  position  or  lying  upon  its  left  side  upon  an  attendant's 
lap.  In  oder  to  control  its  hands  it  should  first  be  enveloped 
in  a  sheet.  With  the  catheter  in  the  stomach,  warm  water  not 
over  100°  F.  is  poured  in  the  funnel,  it  is  then  lowered  and  the 
stomach  contents  siphoned  out,  this  process  being  repeated  a 
number  of  times  until  the  wash  water  returns  clear. 


250  THE   DISEASES   OP    CHILDREN. 

Plain,  boiled  water  is  best  thouijli  a  solution  of  bicarbonate  of 
soda  can  be  used  if  the  vomitus  is  very  acid  smelling. 

After  the  water  has  been  returned  clear  for  two  or  three  si- 
phonages,  from  2  to  3  ounces  of  water  are  poured  in  the  stomach, 
the  tube  tightly  pinched  between  the  fingers  and  quickly  with- 
drawn. Pinching  of  the  tube  prevents  any  drops  from  escaping 
into  the  larynx  as  the  tip  of  the  tube  slips  over  it.  This  water 
is  nearly  always  retained  and  allays  thirst. 

The  stomach  should  have  absolute  rest  for  three  or  four  hours 
after  lavage,  and  for  the  first  12  hours,  at  least,  nothing  but 
water  given  by  the  mouth.  After  the  lavage  calomel  should  be 
given,  ^  grain  at  one  dose  for  a  child  of  six  months,  1  grain  to 
a  child  of  one  year.  One  grain  of  calomel  for  each  year  of  age 
up  to  five  years,  5  grains,  can  be  given  with  the  greatest  benefit 
in  these  cases. 

Even  in  breast-fed  infants  nursing  should  be  resumed  most 
carefully.  The  breast  should  be  emptied  regularly  and  the  milk 
thrown  away  until  nursing  can  be  begun.  In  the  artificially 
fed,  milk  should  be  returned  to  more  slowly. 

When  all  nausea  has  ceased  and  the  movements  are  improved 
give  dextrinized  barley  water,  then  whey  and  barley  water  or 
one  of  the  animal  broths,  plain  or  with  barley  water;  albumen 
water,  if  there  is  not  a  great  deal  of  gas.  Care  should  be  exer- 
cised in  the  amount  of  food  which  is  given  at  a  feeding,  at  first 
1  or  2  teaspoonfuls,  then  ^  an  ounce,  and,  finally,  the  usual 
quantity  taken  by  the  child. 

But  little  medication  is  called  for  in  these  cases  other  than 
the  calomel.  Good  results  are  often  had  from  cerii  oxalatis,  2 
grains  every  two  or  three  hours,  where  the  nausea  persists  after 
the  cessation  of  the  vomiting. 

Should  constipation  follow  the  active  symptoms,  the  bowels 
are  best  controlled  by  the  use  of  enemata  or  glycerine  supposi- 
tories, rather  than  by  the  administration  of  laxatives  or  purga- 
tives, which  may  cause  nausea  or  vomiting  again. 

Hydrotherapy  should  be  used  to  control  the  temperature. 

Eest  in  bed  is  most  essential  and  the  child  should  not  be  held 
or  coddled. 


DISEASES  OP   THE   DIGESTIVE   SYSTEM,  251 

ACUTE  GASTRITIS. 

Etiology. — Any  of  the  causes  of  acute  gastric  indigestion,  if 
prolonged,  may  cause  this  condition,  or  if  the  child  is  in  a  par- 
ticularly run-down  condition  an  acute  catarrh  may  result  in 
an  acute  gastritis.  It  may  complicate  the  exanthemata,  influ- 
enza, diphtheria  or  pneumonia,  and  is  frequently  secondary  to 
acute  inflammatory  conditions  of  the  intestinal  tract.  The  in- 
gestion of  any  of  the  caustic  irritants  will  cause  it. 

Pathology. — The  stomach  may  be  found  contracted  or  dilated, 
usually  the  former,  the  mucous  membrane  is  congested,  thick- 
ened, softened  and  covered  with  a  thick  mucus,  with  more  or 
less  food  free  in  its  cavity.  Macroscopically  but  little  can  be 
detected,  a  small  hemorrhagic  area  may  be  seen.  Micro.scopic- 
ally  the  inflammation  is  seen  to  be  mostly  tubular,  the  epithelium 
is  shed. 

If  the  inflammation  is  due  to  the  swallowing  of  caustic  poi- 
sons there  are  areas  of  ulceration,  the  congestion  is  much  more 
intense  and  the  mucous  membrane  more  swollen. 

S3niiptoms. — The  onset  is  similar  to  that  of  gastric  indigestion, 
pain,  vomiting  and  fever.  The  vomitus  at  first  is  food,  then 
mucus,  which  may  be  blood-tinged,  there  is  diarrhea,  during  the 
acute  stage,  followed  later  by  constipation.  The  temperature 
is  not  as  high  as  in  indigestion  and  gradually  disappears  as  the 
disease  progresses  toward  a  favorable  termination.  The  dura- 
tion of  the  attack  is  from  five  to  seven  days. 

Prognosis. — In  the  robust  the  prognosis  is  good,  in  the  weak 
and  athreptie  it  is  not  so  favorable.  The  danger  in  the  form 
due  to  the  ingestion  of  caustic  substances  is  in  a  stricture  of  the 
cardiac  orifice  of  the  .stomach.  It  may  result  in  a  chronic  gas- 
tritis or  severe  inflammatory  conditions  of  the  intestines. 

Treatment. — The  early  treatment  is  practically  that  of  an 
acute  indigestion,  rest  in  bed,  evacuation  of  the  stomach,  even 
if  resort  must  be  had  to  the  stomach  tube.  The  stomach  washing 
can  be  repeated  daily  or  oftener,  if  necessary,  and  starvation. 

The  phy.sician  must  have  entire  control  of  the  diet  of  the 
patient.  Proper  food  must  be  given,  and  this  means  properly 
selected,  prepared  and  administered,  and  at  the  proper  intervals. 


252  THE   DISEASES   OP    CHILDREN. 

Dextrinized  barley  water  should  be  first  given,  and  if  tol- 
erated, in  a  few  feedings  some  milk,  in  very  small  quantities, 
can  be  added  to  it,  preferably  centrifugal  skim  milk  which  con- 
tains much  less  than  1  per  cent  of  fat.  Buttermilk  will  fre- 
quently be  tolerated  when  whole  or  skimmed  cow's  milk  will  not. 

Hydrotherapy  should  be  used  exclusively  for  high  tempera- 
ture. If  there  is  much  thirst  and  the  vomiting  continues,  a 
high  saline  enema  will  prove  of  service. 

Bismuth  in  large  doses,  60  grains  in  the  24  hours,  is  a  valu- 
able agent  in  this  condition. 

Ti.  Bismuth  subnitrat  3iiss 

Syr.  rhei  aromat  3i 

Aquae  dest.  q.s.  ad         3" 

M.    (Shake.)      Sig:  One  teaspoonful. 
A  daily  .or  twice  daily  bath  should  be  given ;  when  there  is  a 
rise  in  temperature,  it  can  be  used  oftener. 

CHRONIC  GASTRITIS. 

A  chronic  inflammatory  condition  of  the  stomach,  occurring 
independently  or  with  a  similar  condition  in  the  bowels.  There 
may  be  but  slight  change  in  the  mucous  membrane,  the  symp- 
toms being  from  the  functional  disturbances  present. 

Etiology. — A  single  attack  of  acute  gastritis,  or  prolonged 
attacks  may  result  in  the  chronic  form.  It  is  much  more  apt 
to  occur  in  hospital  infants  and  those  who  are  run  down  from 
any  cause,  and  in  those  who  live  in  squalor  and  unhygienic  sur- 
roundings. Any  of  the  diseases  of  nutrition,  as  rachitis,  tuber- 
culosis, anemia,  are  direct  predisposing  causes.  Improper  food, 
bananas,  tea  and  coffee,  pastries  and  sweets,  may  act  as  a  cause. 

Pathology. — The  mucous  membrane  is  thickened  and  shed 
largely  of  its  epithelium ;  there  is  much  more  mucous  on  the 
surface  of  the  membrane  than  in  the  acute  form,  and  frequent 
lavage  is  often  needed  before  the  stomach  is  entirely  rid  of  it. 
It  is  so  tenacious  that  a  large  quantity  of  water  may  be  needed  to 
entirely  remove  it.  The  stomach  wall  is  thickened  and  the 
stomach  itself  distended.     The  solitarv  follicles  are  enlarged. 

Symptoms. — Frequent   vomiting   without   apparent   cause   is 


DISEASES  OP   THE  DIGESTIVE  SYSTEM.  253 

the  most  regular  symptom,  and  often  undigested  food  is  vom- 
ited several  hours  after  it  is  eaten. 

This  is  due  to  the  interference  with  the  motor  function  of 
the  stomach  walls  from  the  inflammation  and  the  distension,  and 
to  the  perverted  stomach  juices. 

There  are  frequent  attacks  of  colic;  coated  tongue,  rapid  loss 
in  weight ;  sour  breath,  the  muscles  are  flabby ;  the  skin  assumes 
a  yellowish  color;  the  bowels  are  constipated  at  first,  followed 
by  diarrhea ;  there  is  a  loss  of  appetite ;  loss  of  sleep  and  rest- 
lessness ;  circulation  is  poor,  and  extremities  cold.  The  child 
may  live  for  a  long  while,  wasting  rapidly  and  die  suddenly 
at  the  end,  when  death  has  hardly  been  expected. 

Prognosis. — In  general  this  is  not  good,  unless  the  physician 
has  constant  and  direct  control  of  the  diet,  hygiene  and  life  of 
the  child.  Intestinal  involvement  influences  the  prognosis  badly. 
Recovery  is  slow. 

Diagnosis. — The  principal  condition  to  be  borne  in  mind 
is  that  of  pyloric  stenosis,  considered  in  another  place  (see  page 
243).  Chronic  gastritis  is  not  apt  to  occur  in  the  newly-born,  in 
whom  pyloric  stenosis  is  most  often  seen. 

Treatment. — As  already  stated  the  physician  must  be  in  con- 
trol of  the  child  as  to  its  habits,  hygiene,  mode  of  life  and  diet. 
A  change  of  climate  is  often  of  the  greatest  benefit.  Stomach 
lavage  daily,  then  every  other  day  until  vomiting  is  relieved, 
should  be  practiced.  These  patients  should  live  out  of  doors 
at  all  seasons,  well  protected  by  flannel  band  and  underwear, 
and  outside  wraps  in  winter.  The  feet  should  be  frequently 
inspected  and  hot-water  bottle  used  if  needed.  Woolen  stock- 
ings should  be  worn.  Daily  tub  baths,  followed  by  a  cocoanut- 
oil  rub,  should  be  given.  The  hygienic  care  should  include  the 
frequent  change  of  napkins  as  soon  as  soiled  or  wet,  and  their 
proper  cleansing. 

The  diet  is  most  important.  If  breast  fed  an  analysis,  as 
complete  as  possible,  must  be  made  of  the  mother's  milk.  If 
over  rich  in  fat,  an  attempt  made  to  regulate  this  ingredient. 
If,  in  spite  of  every  effort  to  change  the  character  of  the  milk, 
the  vomiting  continues  a  wet  nurse,  whose  baby's  age  approxi- 
mates the  patient's  may  be  procured.     If  this  is  unsuccessful, 


254  THE   DISEASES   OP    CHILDREN. 

resort  should  be  had  at  once  to  a  modified  milk,  at  first  prac- 
tically eliminating  the  fat  content.  This  can  best  be  done  by 
utilizing  a  centrifugal  milk  in  which  the  fat  lias  been  reduced 
below  1  per  cent,  or  a  fat-free  buttermilk  made  with  the  lactone 
tablet  can  be  used.  If  this  is  retained  the  prescription  can  be 
increased  slowly  by  addition  of  .25  per  cent  of  fat  daily,  or 
every  other  day,  until  2  per  cent  has  been  reached,  unless  vom- 
iting recurs  when  the  fat-free  mixture  is  again  used. 

Fat-free  whey  diluted  with  equal  parts  of  barley  water  is 
frequently  well  borne.  The  first  essential  in  regard  to  the  milk 
is  that  it  should  be  either  certified  or  inspected. 

If  milk  is  not  tolerated  in  any  form,  after  lavage,  give  dex- 
trinized  barley  water  in  small  quantity,  by  gavage  at  first,  then 
in  2  or  3  teaspoonful  quantities,  gradually  increasing  the 
amount. 

The  animal  broths  are  frequently  well  borne,  or  beef  juice, 
expressed  immediately  before  feeding  and  diluted  with  quite 
warm  water  to  prevent  its  coagulating. 

It  may  be  necessary  to  continue  the  use  of  gavage  for  several 
days. 

One  great  mistake  is  made  in  these  cases  in  trying  so  many 
foods  in  a  short  space  of  time.  Kind  neighbors  and  friends 
harass  the  mother  frantic  by  suggestions  as  to  this  or  that  food, 
and  the  physician  is  asked  in  regard  to  each  new  one  in  turn. 

It  is  a  mistake  to  believe  these  athreptic  infants  need  alcohol. 
It  is  the  worst  remedy  which  can  be  used,  and  is  responsible  for 
much  trouble.  In  giving  the  proprietary  preparations  panopep- 
tone  and  peptonoids,  their  alcoholic  ingredient  must  be  remem- 
bered. 

If  the  vomitus  is  very  sour  good  results  are  sometimes  ob- 
tained from  the  use  of  bicarbonate  of  soda  in  the  wash  water 
in  the  proportion  of  a  teaspoonful  to  the  pint  of  water. 

But  little  medication  is  needed  or  can  be  given  in  these  cases. 
Save  the  stomach  for  food  which  is  most  needed.  Fowler's 
solution  of  arsenic  is  of  service,  in  drop  doses  in  water  three 
times  a  day,  and  strychnia  sulphate,  gr.  3/200,  to  a  child  of  one 
year,  assists  in  toning  up  the  stomach  muscle. 

If  constipation  is  present  it  can  best  be  controlled  by  use  of 


DISEASES  OP   THE  DIGESTIVE  SYSTEM.  255 

enemata  and  glycerine  suppositories,  alternated,  each  morning 
at  the  same  time,  the  child  being  placed  on  its  chair  immediately 
after  its  use. 

GASTRIC  DILATATION  (GASTRECTASIA). 

This  condition  should  be  differentiated  from  an  enlarged  ab- 
domen, so-called  pot  belly,  which  is  so  frequent  in  yearlings  or 
during  the  second  year,  this  most  often  being  due  to  a  dilata- 
tion of  the  colon.  • 

Etiology. — The  most  frequent  cause  in  new-born  babies  is 
pyloric  obstruction  or  stenosis.  The  next  is  a  stretching  of  the 
muscular  wall  due  to  fermentation  and  decomposition  of  the 
food  contents,  as  occurs  in  chronic  gastritis.  It  is  a  manifesta- 
tion of  general  nutritional  disorders  as  in  rachitis  and  tuber- 
culosis. Frequent  attacks  of  acute  indigestion ;  too  frequent 
eating  and  improper  foods  are  also  causes. 

Pathology. — The  changes  in  the  stomach  vary  in  these  cases, 
as  found  postmortem ;  often  great  evidences  of  chronic  gastritis 
are  present.  The  degree  of  dilatation  also  varies,  as  postmortem 
change  may  show  considerable  contraction  in  a  stomach  which 
had  been  shown  to  be  enlarged  before  death, 

S3niiptoms. — These  are  as  outlined  in  the  previous  section  in 
chronic  vomiting ;  sluggish  circulation ;  waxy  color ;  cold  ex- 
tremities ;  thirst ;  poor  appetite ;  coated  tongue ;  high-colored 
urine;  constipation.  Percussion  shows  an  increased  area  of 
stomach  resonance,  perhaps  below  the  umbilicus,  and  this  is  con- 
firmed by  introduction  of  water  slowly  through  the  stomach  tube 
to  point  of  tolerance.  Air  injected  into  the  stomach  should  never 
be  employed  as  a  diagnostic  procedure  in  a  child  because  of  the 
danger  of  rupture  of  the  stomach. 

Prognosis  depends  upon  the  cause,  and  if  not  organic  upon 
the  early  diagnosis  and  early  removal  of  the  cause. 

Treatment  is  practically  that  of  chronic  gastric  catarrh.  Re- 
lieve the  stomach  of  its  fermenting  contents,  with  sufficient  wash 
water  to  have  it  return  entirely  clear.  "Wash  daily  at  first  then 
twice  and  finally  once  a  week,  continuing  several  weeks  at  least. 
Small  quantity  of  food,  predigested  at  first,  at  two  or  three 
hourly  intervals,  liquids  entirely  at  first. 


256  THE  DISEASES   OF    CHILDREN, 

Nux  vomica,  1  or  2  drops  of  the  tincture  to  a  child  of  two 
years  three  times  a  day,  well  diluted,  is  beneficial.  Careful 
attention  to  the  bowels,  the  wearing  of  an  abdominal  binder; 
daily  baths,  general  rubbing,  and  moderate  exercise  in  the  fresh 
air  will  be  found  very  beneficial. 


CYCLIC  VOMITING. 

Known  al«o  as  recurrent  or  periodic  vomiting.  It  is  a  condi- 
tion characterized  by  severe  vomiting  and  prostration  wdth  but 
little  fever  as  a  rule,  in  which  no  active  cause,  as  indiscretions  of 
diet,  can  be  traced. 

Etiology. — This  is  obscure  and  has  been  the  subject  of  much 
conjecture.  It  is  doubtless  due  to  an  increased  acidity  of  the 
fluids  of  the  body  from  some  disturbance  of  elimination  and 
absorption.  There  is  an  acetone  odor  to  the  breath,  and  symp- 
toms of  a  toxemia  are  present.  Acetone  bodies,  diacetic  acid 
and  oxybutyric  acid  are  found  in  the  urine.  There  seems  to  be 
a  fairly  uniform  decrease  in  uric  acid  elimination.  The  basis 
of  the  trouble  seems  to  be  a  disturbance  of  metabolism  rather 
than  an  error  of  digestion.  My  own  cases  have  failed  to  reveal 
any  uniform  digestive  disturbance  preceding  the  attacks,  or  any 
special  article  of  diet  as  responsible  for  them.  The  starchy 
foods  have  been  thought  by  some  to  be  a  cause. 

Symptoms. — Cyclic  vomiting  rarely  occurs  in  infancy,  but 
is  more  frequently  seen  in  children  between  5  and  10  years  of 
age.  My  cases  have  been  about  evenly  divided  in  the  sexes, 
though  girls  are  said  by  some  observers  to  be  most  often  affected. 

The  onset  is  usually  sudden,  and  without  any  dietary  indiscre- 
tions. The  vomiting  may  begin  in  the  night,  or  the  child  wakens 
in  the  morning,  heavy  and  dull,  and  complains  of  nausea,  per- 
haps of  pain  in  the  abdomen,  which  is  soon  followed  by  vom- 
iting. If  vomiting  occurs  at  night  the  supper  may  be  vomited 
undigested,  if  later  in  the  morning,  the  first  vomitus  may  be  only 
fluid.  The  child  continues  to  vomit  at  frequent  intervals,  with 
retching  between,  the  vomitus  being  principally  mucus,  perhaps 
bile-stained  and  a  few  streaks  of  blood.  Any  attempt  to  admin- 
ister medicine,  food  or  water  results  in  its  rejection  at  once. 


DISEASES   OF   THE   DIGESTIVE   SYSTEM,  257 

As  a  result  of  the  continuous  vomiting  and  retching,  pros- 
tration develops  early,  the  pulse  is  accelerated,  the  child  drops 
back  after  each  attack  prostrated,  the  face  is  pallid,  the  eyes 
sunken,  lips  and  tongue  parched,  the  latter  coated;  abdomen 
retracted,  urine  highly  colored  and  scant,  and  the  characteristic 
sweetish  or  acetone  odor  to  both  the  urine  and  the  breath. 

As  a  rule  there  is  no  temperature,  though  in  one  of  my  cases 
the  temperature  rose  to  102°  F.  in  a  number  of  attacks.  Con- 
stipation is  the  rule,  though  usually  a  movement  can  be  obtained 
by  an  enema. 

The  duration  of  the  attack  is  always  30  to  48  hours,  and  it 
may  last  for  three  or  four  days.  The  frequency  of  the  vomit- 
ing is  gradually  lessened  as  the  disease  progresses,  and*  I  have 
seen  a  child  in  an  hour's  time  after  severe  vomiting  call  for 
water  and  retain  it  and  everything  given  subsequently.  There 
is  no  regularity  as  regards  the  time  of  the  recurrence  of  the 
attacks.  One  of  my  cases,  under  observation  for  two  years  or 
more,  had  a  recurrence  on  an  average  of  once  every  four  months, 
though  not  regularly  at  that  interval.  In  this  case  the  attacks 
were  undoubtedly  rendered  less  severe  and  more  infrequent 
by  the  alkaline  treatment. 

Diagnosis. — The  diagnosis  must  be  made  between  meningitis, 
appendicitis  and  organic  lesions  of  the  kidney.  The  failure  of 
brain  symptoms  to  appear  eliminates  meningitis  from  considera- 
tion, though  it  should  always  be  thought  of.  Urinary  analysis 
is  of  importance  in  ruling  out  kidney  lesions,  and  this  is  a 
diagnostic  aid  which  is  too  frequently  overlooked. 

The  presence  of  acetone  in  the  urine  is  confirmatory  evidence 
of  cyclic  vomiting.  Among  the  tests  for  acetone  are  the 
following :  1 

1.  Lichen's  Iodoform  Test,  as  modified  by  Ralfe,  is  as  fol- 
lows :  20  grains  of  potassiinn  iodide  are  dissolved  in  a  drachm 
of  liquor  potassa'  and  boiled ;  the  urine  is  then  floated  upon  the 
surface  of  the  fluid  in  a  test  tube.  At  the  point  of  contact  a 
precipitation  of  phosphates  occurs,  which,  if  acetone  be  present, 
becomes  yellow  and  studded  with  yellow  points  of  iodoform. 

A  more  delicate  method  of  application  of  this  test  is  to  first 
distill  a  small  quantity  of  the  urine  and  apply  the  test  to  the 

1  Purdy:      "Practical  Uranalysis." 


258  THE  DISEASES  OF   CHILDREN. 

distillate.     This  test  has  one  disadvantage ;  lactic  acid  and  ethyl 
alcohol  behave  with  it  similarly  to  acetone. 

2.  Chautard's  Test.  A  drop  of  aqueous  solution  of  magenta 
decolorized  by  sulphurous  acid  gives,  with  fluids  containing 
over  0.01  per  cent  of  acetone,  a  violet  color.  This  appears  in 
dilute  solutions  after  four  or  five  minutes. 

3.  Le  Noble's  Test.  On  adding  an  alkaline  solution  of  so- 
dium nitroprusside — so  dilute  as  to  have  only  a  slight  red  tint — 
to  a  fluid  containing  acetone  a  ruby-red  color  is  produced,  which 
in  a  few  minutes  changes  to  yellow,  and  on  boiling,  after  adding 
acid  to  a  greenish-blue  or  violet.  A  quarter  of  a  milligramme  of 
acetone  can  be  thus  detected. 

4.  Baeyer's  Indigo  Test.  A  few  crystals  of  nitrobenzalde- 
hyde  are  dissolved  by  heat  in  the  suspected  urine;  on  cooling 
the  aldehyde  separates  in  the  form  of  a  white  cloud.  The  mix- 
ture is  then  made  alkaline  with  dilute  sodium  solution,  and,  if 
acetone  be  present,  first  yellow,  then  green,  and  lastly  an  indigo- 
blue  color  will  appear  within  10  minutes. 

5.  Reynold's  Test.  This  test  depends  upon  the  fact  that 
acetone  promotes  the  solution  of  mercuric  oxide.  The  test  may 
be  conducted  as  follows :  The  yellow  precipitate  of  mercuric 
oxide,  obtained  by  the  reaction  of  mercuric  chloride  with  an 
alcoholic  solution  of  potassium  hydrate  is  added  to  a  small 
quantity  of  the  urine,  which  is  shaken  and  filtered.  To  the  clear 
filtrate  ammonium  sulphate  is  carefully  added,  and  if  acetone 
be  present  some  of  the  mercuric  oxide  is  dissolved  and  a  black 
ring  of  sulphide  of  mercury  appears  at  the  plane  of  contact  be- 
tween the  two  liquids. 

Prognosis. — A  few  cases  have  been  reported  with  fatal  ter- 
mination, but  these  are  very  unusual.  They  recover  in  from 
two  to  four  days. 

Treatment. — Active  treatment  during  the  attack  is  of  no  ser- 
vice. Nothing  should  be  given  by  the  mouth  except  perhaps 
a  preliminary  draught  of  water  for  the  purpose  of  washing  the 
stomach  as  it  is  immediately  vomited.  The  best  results  are  ob- 
tained from  high  rectal  injections,  first  for  the  purpose  of  evacua- 
tion and  followed  by  an  injection  of  a  solution  of  bicarbonate  of 
soda,  2  drachms  to  the  pint,  with  the  purpase  of  having  it  re- 


DISEASES   OF    THE   DIGESTIVE   SYSTEM.  259 

tained.  These  enemata  should  be  alternated  at  four-hour  inter- 
vals with  predigested  milk  in  quantities  not  to  exceed  4  ounces 
given  through  a  catheter  into  the  sigmoid  if  possible. 
,  If  the  retching  is  very  severe  and  the  prostration  extreme, 
the  use  of  codeine,  sulphate,  grain  i/8»  to  a  child  of  five  years,  or 
morphia  sulphate,  grain  Y^.^,  will  give  good  results. 

As  soon  as  the  vomiting  ceases  and  the  child  asks  for  water 
it  can  be  given  tentatively.  Crushed  ice  at  first,  small  quantity 
of  water,  and  repeated  in  larger  amounts  at  short  intervals, 
then  a  broth  followed  by  diluted  skimmed  milk.  As  soon  as 
possible  a  cathartic  should  be  given,  cascara  or  a  part  of  a  bottle 
of  citrate  of  magnesia. 

In  the  interval  between  the  attacks,  the  regular  administra- 
tion of  bicarbonate  of  soda  in  3  grain  doses,  four  times  a  day, 
over  a  period  of  three  or  four  weeks,  with  a  week's  rest,  and  a 
resumption  of  it  at  the  end  of  that  time  for  another  three  weeks, 
and  so  on  for  four  months,  will  lengthen  the  interval  between 
attacks.     ]Milk  of  magnesia  can  also  be  used  with  benefit. 

The  diet  should  be  a  mixed  one,  a  very  moderate  amount  of 
meat,  and  sparingly  of  cereals,  no  raw  fruits,  otherwise  the  diet 
is  not  restricted. 

If  an  attack  seems  imminent  tlie  dose  of  soda  should  be  in- 
creased to  double,  6  grains  every  three  hours. 

Some  children  cannot  be  persuaded  to  take  the  soda  by  the 
mouth.  This  was  the  case  with  one  of  my  patients  who  readily 
submitted  to  its  administration  twice  daily  in  an  enema. 

If  there  is  a  history  of  rheumatism  the  salicylates  should  be 
given  but  not  as  a  routine. 

COLIC. 

Special  consideration  of  this  symptom  is  made  necessary  be- 
cause of  the  frequency  with  which  it  is  encountered  in  infancy. 
It  must  be  borne  in  mind,  however,  that  the  average  mother 
or  nurse  attributes  every  crying  spell  an  infant  has  to  the  colic, 
and  a  popular  belief  among  the  laity  is  that  every  child  is  likely 
to  have  colic  until  it  is  three  months  old. 

When  a  history  is  given  of  crying,  with  a  tense  abdomen  and 
audible  rumbling  of  gas  in  the  intestine  and  the  frequent  eructa- 


260  THE   DISEASES   OF    CHILDREN. 

tion  of  gas  from  the  stomach,  the  condition  is  probably  one  of 
colic,  but  the  frequency  with  which  serious  intraabdominal  con- 
ditions may  develop  with  colicky  pains  in  the  abdomen  as  the 
chief  symptom,  makes  it  necessary  for  careful  consideration  to  ba 
given  each  case  in  which  abdominal  pain  is  a  feature. 

The  colic  which  occurs  in  both  breast  and  artificially  fed  in- 
fants is  due  to  a  fermentation  in  the  stomach  and  intestines  of 
the  food  ingested  and  the  rapid  accumulation  of  gas,  the  pain 
being  caused  by  its  passing  rapidly  from  the  stomach  or  through 
a  knuckle  of  gut.  It  may  also  be  due  to  a  spasmodic  condition 
of  the  intestine,  produced  by  an  undigested  mass  of  food  acting 
as  an  irritant  as  it  passes  through  the  bowel.  In  the  artificially 
fed  a  too  large  carbohydrate  content  or  the  use  of  undextrinized 
cereal  diluent  may  be  the  cause  of  the  rapid  fermentation. 

A  breast-fed  child  may  nurse  too  quickly  from  a  very  full 
breast  and  swallow  some  air  with  the  milk.  It  may  stop  in  the 
midst  of  a  nursing,  throw  off  the  gas,  and  resume  the  nursing. 
If  held  for  a  moment  on  the  shoulder,  with  its  abdomen  l>eing 
pressed  upon,  this  eructation  is  facilitated. 

If  the  rubber  nipple  through  which  an  artificial  feeding  is 
taken  allows  the  milk  to  flow  too  freely,  this  same  condition 
may  obtain,  or  if  the  milk  is  taken  too  cold  the  tendency  to  gas 
formation  is  increased.  Too  frequent  feeding  is  also  a  cause,  the 
effect  being  an  indigestion  with  fermentation. 

Symptoms. — The  chief  symptom  of  colic  is  pain  in  the  ab- 
domen, which  causes  the  child  to  cry  out,  the  abdomen  is  tense, 
and  with  the  hand  on  the  abdomen  the  gas  can  be  felt  as  it  moves 
in  the  intestines.  The  weight  of  the  hand  may  sometimes  give 
relief.  The  symptoms  develop  shortly  after  a  feeding  or,  as' 
already  stated,  may  come  while  nursing,  either  from  the  breast 
or  bottle,  due  to  swallowing  air  with  the  milk. 

The  child  is  restless  and  fretful,  its  feet  and  hands  are  cold, 
and  it  cannot  be  pacified  in  any  position.  It  may  fall  asleep 
in  the  midst  of  its  crying  and  waken  with  a  start  to  resume. 

It  is  not  uncommon,  especially  in  the  artificially  fed,  when 
the  carbohydrate  content  of  the  milk  is  responsible  for  the  gas 
formation,  for  the  symptoms  to  develop  several  hours  after  a 
feeding,  and  the  child  may  remain  awake  most  of  the  night. 


DISEASES  OF   THE   DIGESTIVE   SYSTEM.  261 

Relief  comes  almost  immediately  after  the  gas  is  passed  and 
the  child  falls  into  a  restful  sleep. 

Diagnosis. — This  must  be  made  from  appendicitis,  intussus- 
ception and  dciite  middle-ear  inflamtnation. 

In  appendicitis  there  is  an  area  of  tenderness  and  localized 
rigidity.  In  colic  the  weight  of  the  hand  often  affords  relief, 
and  the  whole  abdomen  is  rigid. 

In  intussusception  a  tumor  is  apt  to  develop  early,  which  is 
associated  with  acute  constipation  and  bloody  discharges. 
Bloody,  mucous  movements  may  be  present  in  the  colic  which 
is  present  in  acute  gastroenteritis,  but  in  the  ordinary  form  of 
colic  here  described  these  stools  are  not  seen. 

In  the  acute  middle-ear  inflammations  the  child  puts  its  hand 
to  the  affected  side  or  picks  at  the  ear,  and  the  character  of  the 
cry  is  different,  it  being  more  shrill  and  piercing  than  the  cry 
from  colicky  pains. 

Treatment. — Prevention.  Care  must  be  exercised  as  to  the 
feeding  of  the  child,  regularity,  quantity,  frequency,  and  in  the 
artificially  fed  the  food  prescriptions  should  be  carefully  con- 
sidered. If  the  child  is  newly  put  upon  artificial  food  the  first 
food  prescription  must  be  weaker  than  is  necessary  for  the  child 's 
needs,  and  gradually  increased  until  it  gains  in  weight,  in  order 
that  its  digestion  be  not  upset  in  the  beginning. 

If  on  the  breast,  the  breast  milk  should  be  clinically  examined 
by  the  Holt  milk  set,  and  any  ingredient  found  at  fault  corrected, 
as  indicated  in  a  previous  chapter. 

During  the  attack,  those  remedies  are  indicated  which  will 
assist  in  the  dislodgement  of  the  gas.  If  the  gas  seems  high 
up  the  administration  of  peppermint  water,  half  teaspoonful  in 
water,  will  assist  the  child  in  belching. 

The  elixir  of  catnip  and  fennel  in  10  or  15  drop  doses  is  a 
serviceable  remedy.  Hot  applications  to  the  abdomen,  the  weight 
of  the  hand  on  the  abdomen,  letting  the  child  lie  upon  a  hot- 
water  bag  on  a  pillow,  face  down,  holding  it  over  the  shoulder, 
causing  pressure  on  the  abdomen,  are  means  which  are  of  service 
in  obtaining  comfort. 

A  warm  enema,  given  through  a  catheter  introduced  more 
than  half  its  length,  containing  a  few  drops  of  turpentine,  will 


262  THE   DISEASES   OF    CHILDREN. 

dislodge  gas  low  down  in  the  intestine  and  often  produce  com- 
plete relief. 

Soothing  syrups  should  never  be  given  as  they  all  contain 
opium.  Opium  should  not  be  given  under  any  conditions  as 
a  routine,  in  fact,  only  as  a  last  resort.  If  it  is  decided  that 
opium  is  imperatively  needed,  paregoric  is  the  best  form,  in  10 
or  15  drop  doses,  well  diluted.  The  bromides  are  safe,  and  can 
be  used  if  the  child  is  very  restless  and  cannot  be  quieted  or  get 
to  sleep. 

6ASTRALGIA. 

A  sudden  and  severe  pain  in  the  abdomen,  principally  in  the 
epigastrium,  which  cannot  be  traced  to  an  indiscretion  in  the 
diet  or  any  definite  lesion  of  the  viscera. 

It  is  considered  to  be  a  neurosis,  a  neuralgia  affecting  the 
nerves  of  the  stomach. 

We  know  nothing  which  is  definite  of  the  etiology  or  path- 
ology of  this  condition.  It  is  more  than  likely  associated  with 
the  rheumatic  diathesis,  whatever  that  may  be. 

Diagnosis  and  Symptoms. — The  symptoms  of  gastralgia  are 
best  considered  under  the  head  of  differential  diagnosis. 

Children,  as  a  rule,  do  not  locate  pain  accurately,  hence  when 
a  pain  is  referred  to  the  epigastrium  other  conditions  may  be 
present  which  may  have  pain  as  a  principal  symptom,  but  re- 
ferred to  near  or  remote  organs.  Among  these  may  be  men- 
tioned a  diaphragmatic  pleurisy,  pneumonia  with  small  pleural 
involvement,  vertebral  caries  of  the  middorsal  region,  intercostal 
neuralgia,  inflammation  of  the  pericardium,  endocardium,  or  the 
appendix. 

An  investigation  of  the  regions  giving  rise  to  these  conditions 
will  usually  rule  out  the  more  serious  conditions.  The  pain 
in  a  gastralgia  is  usually  more  or  less  spasmodic,  entire  relief, 
except  perhaps  a  slight  feeling  of  soreness  being  experienced  in 
the  interim  between  attacks.  Rarely  there  may  be  nausea,  and 
more  rarely  vomiting  caused  by  the  pain  entirely,  and  with  no 
signs  or  symptoms  of  indigestion. 

Appendicitis  should  be  carefully  excluded  in  making  a  diag- 
nosis of  this  condition. 

Treatment. — TJe.st  in  bed :  heat,  either  moist  or  dry,  over  the 


DISEASES  OF    THE   DIGESTIVE  SYSTEM.  263 

abdomen  and  epigastrium ;  counter  irritation  by  a  sinapism  of 
mustard  or  turpentine  stupe  and  hot  water  internally,  in  which 
has  been  put  a  few  drops  of  camphor.  During  the  interim  put 
the  child  on  tonic  treatment.  Fowler's  solution  in  gradually 
increasing  doses  of  a  drop  at  a  time,  until  the  point  of  toleration 
is  produced,  and  change  of  food,  scene  and  air. 

ACUTE  GASTROENTERIC  INFECTION. 
Synonyms. — Acute  gastroententis,  summer  diarrhea,  summer 

complaint. 

Etiology. — There  is  always  a  causal  relation  between  the  food 
ingested  and  the  development  of  this  condition,  infected  milk  be- 
ing most  frequently  the  cause  in  the  artificially  fed.  Statistics 
uiiiversally  show  the  highest  mortality  rate  am.ong  bottle-fed 
children  during  the  first  year.  It  occurs  in  the  breast  fed  from 
improper  and  irregular  feeding,  and  frequently  in  those  partly 
nursed  and  partly  artificially  fed.  It  is  most  often  seen  in  the 
hot  summer  months  though  it  may  occur  in  winter. 

Institution  and  tenement  house  babies  are  frequently  affected. 

Milk  in  the  various  steps  of  its  handling  from  the  cow  to  the 
consumer  is  more  frequently  contaminated  than  any  other  article 
of  food,  and  being  an  excellent  culture  medium  both  pathogenic 
and  non-pathogenic  organisms  develop  with  great  rapidity  if  con- 
ditions are  favorable.  The  toxins  developed  by  the  bacteria  in 
the  milk  before  and  after  ingestion  are  responsible  for  the  ma- 
jority of  the  symptoms  present  as  well  as  for  the  invasion  of  the 
bacteria  in  the  intestinal  wall. 

Many  organisms  have  been  identified  in  examination  of  stools 
from  children  affected  with  gastroenteric  catarrh  or  infection. ' 
The  colon  group  is  most  often  identified,  and  Escherich  has  shown 
that  this  group  can  develop  great  virulency.  Streptococci  are 
also  found,  especially  the  streptococcus  enteritis  which  Booker 
claims  is  of  great  importance  as  a  causative  factor. 

Many  other  bacteria  are  found  among  which  may  be  named 
the  bacillus  subtilis,  bacillus  pyocyaneus,  proteus  vulgaris. 

Pathology. — One  who  does  much  postmortem  work  in  these 
cases  will  be  impressed  at  once  with  the  small  amount  of  macro- 
scopic changes  occurring  in  the  stomach  and  intestine  with  the 
history  of  such  severe  symptoms  during  the  last  illness. 


264  THE   DISEASES   OF    CHILDREN. 

Microscopically  there  is  found  a  loss  of  epithelium  in  both 
stomach  and  intestine,  and  a  general  infiltration  of  the  epithe- 
lium. Deep  ulceration  may  rarely  be  found.  The  mucous  mem- 
brane exhibits,  as  a  rule,  a  washed-out  appearance  with  here 
and  there  a  reddened  area,  some  mucus  adhering  to  surface  of 
the  membrane,  and  the  intestine  practically  empty  of  contents. 

The  small  gut  will  often  be  found  contracted  almost  through 
its  whole  extent.     Cloudy  swelling  of  the  kidney  may  be  found. 

Symptoms. — Several  forms  are  described.  It  may  be  mild, 
severe  or  toxic.  Usually  without  warning  the  child  will  vomit, 
often  large  quantities,  apparentlj^  much  more  than  had  been  taken 
at  the  last  feeding.  In  older  children  there  is  apt  to  be  nausea  for 
some  time  after  the  initial  vomiting.  There  is  considerable 
prostration,  the  child  looks  sick,  is  pale  and  restless.  The  tem- 
perature rises  quickly  and  may  be  102°  or  103°  F.  The  stools 
may  at  first  be  normal  but  are  followed  by  undigested,  offensive 
ones  full  of  mucus. 

Prognosis. — In  previously  normal  and  healthy  children  the 
prognosis  is  usually  good,  but  in  the  athreptic  baby  recovery  is 
not  so  prompt,  and  serious  sequelae  are  apt  to  develop. 

In  the  very  young  improvement  is  usually  quite  prompt  or 
the  child  may  quickly  succumb,  or  the  condition  develop  into  a 
chronic  one. 

Treatment. — Prophylaxis  is  of  the  greatest  importance.  A 
breast-fed  child  should  not  be  weaned  in  the  midst  of  the  hottest 
months.  Only  clean,  cold  milk  should  be  used.  If  Certified  milk 
is  not  obtainable  the  best  that  can  be  had  should  be  pasteurized 
and  kept  cold  until  fed.  Scrupulous  cleanliness  of  bottles,  nip- 
ples, etc.,  should  be  insisted  upon. 

As  in  other  gastroenteric  disorders  the  treatment  is  best  con- 
sidered under  (1)  Dietetic;  (2)  ^Medicinal ;  (3)  Hygienic. 

1.  Dietetic.  First  all  food  should  be  immediately  withheld, 
especially  milk,  for  at  least  24  hours.  While  the  nausea  lasts, 
no  food  by  the  mouth  can  be  retained  or  assimilated.  ]\Iilk  in 
any  form  should  not  be  given,  as  no  other  food  offers  so  favorable 
a  culture  medium  for  bacterial  development  when  taken  into 
the  stomach.  Dextrinized  barley  water  is  better  taken  care  of 
than  anything  else,   and  can  be   given  in  small  quantities   at 


DISEASES   OF    THE   DIGESTIVE    SYSTEM.  265 

the  end  of  24  hours,  or  later,  if  the  nausea  and  vomiting  have 
not  stopped  by  that  time.  To  the  barley  water  can  be  added 
a  little  beef  peptonoids  or  panopepton  which  makes  it  more 
palatable  to  some,  and  nutritious  also. 

On  the  third  day  one  of  the  animal  broths,  plain  or  with 
barley  water,  can  be  given,  and  upon  the  return  of  normal 
stools,  practically  free  from  mucus,  milk  can  be  resumed,  at 
first  in  the  form  of  whey,  made  from  fat-free  milk,  and  to  this 
may  later  be  added  small  amounts  of  skimmed  milk,  until  the 
usual  formula  can  be  resumed.  The  first  milk  given  may  be 
in  the  form  of  buttermilk,  made  from  fresh  milk  by  the  addi- 
tion of  the  pure  culture  lactic  acid  bacteria,  and  it  is  frequently 
well  taken  by  children. 

2.  Medicinal.  If  much  nausea  is  present,  calomel,  dry  on 
the  tongue,  is  the  remedy  of  all  others.  To  a  child  of  one  year 
give  1  grain  of  finely-triturated  calomel.  If  not  much  nausea 
is  present  and  the  stools  show  intestinal  irritation  early  a  dose 
of  castor  oil  should  be  given  in  order  to  quickly  sweep  out  the 
decomposing  and  putrid  intestinal  contents. 

If  much  gastric  irritation  is  present  and  neither  remedy  can 
be  retained,  lavage  of  the  stomach  gives  brilliant  results. 

If  the  initial  purgative  is  given  early  and  dietetic  treat- 
ment outlined,  strictly  followed,  further  medicinal  treatment  is 
usually  not  needed,  but  if  the  intestinal  irritation  continues 
several  doses  of  bismuth  subnitrate  may  be  indicated.  The  fol- 
lowing can  be  used  to  advantage : 


IJ   Bismuth  subnitrat  ^^s 

(Merck  or  Squibb) 
Syr.  rhei  aromatici  5iii 

Aquse  destillatae  q.s.  ad   3iii 
M.      (Shake  well.) 
Sig.     One    teaspooiiful    eveiy    two    hours,    until    at    least    six    doses   have 
been  siven. 


To  this  prescription  can  be  added  5  grains  of  tannalbin  to 
each  teaspoonful  if  the  mucus  persists  and  the  evacuations  are 
very  frequent. 

Colon  irrigation  once  daily  with  the  normal  salt  solution  is  of 


266  THE   DISEASES   OF    CHILDREN. 

great  benefit,  especially  early  when  the  nausea  and  vomiting  are 
features  and  there  is  so  much  loss  of  fluids. 

3.  Hygienic  Treatment.  The  most  important  hygienic  treat- 
ment consists  in  the  proper  care  of  the  food  of  the  child  from 
its  production  until  it  is  consumed ;  the  proper  care  of  the  bottles 
and  nipples  and  the  correct  modification  of  the  milk  for  the  indi- 
vidual child.  ]\Iost  of  these  attacks  are  preventable,  and  if  the 
parent  is  correctly  informed  of  the  dangers  attending  carelessness 
of  detail  in  the  preparation  and  handling  of  the  child's  food,  a 
great  deal  of  Ynortality  and  morbidity  will  be  prevented. 

The  child  should  be  warmly  clothed,  wearing  an  abdominal 
binder  at  all  times.  It  should  live  out  of  doors,  well  protected 
in  inclement  weather  in  winter.  Daily  baths  are  most  impor- 
tant, and  during  an  attack  hydrotherapy  for  pyrexia  is  specially 
indicated.  Great  care  should  be  taken  of  the  napkins,  which 
should  be  boiled  before  using  a  second  time.  Regular  feeding, 
according  to  schedule,  is  most  important  and  should  be  insisted 
upon.  It  is  of  as  much  importance  to  give  accurate  written 
directions  in  regard  to  the  preparation,  care  and  administration 
of  the  food  as  it  is  for  medicine.  Do  not  take  anything  for 
granted  when  it  comes  to  the  feeding  of  an  infant,  especially 
during  convalescence  from  an  active  gastroenteric  infection. 

CHOLERA  INFANTUM. 

Definition. — This  term  is  erroneously  applied  to  many  cases 
of  acute  gastrointestinal  disturbances,  which  do  not  all  answer  the 
description  of  this  pathologic  condition.  It  is  a  disease  seen 
in  children  under  three'  years  of  age,  and  is  characterized  by 
great  prostration,  very  rapid  wasting,  profuse  watery  discharges 
from  the  bowel,  vomiting  of  large  quantities  of  fluid,  and  either 
rapid  improvement  as  a  result  of  treatment  or  early  death. 

Etiology. — No  specific  organism  has  been  isolated,  but  the 
symptoms  are  those  of  an  essentially  toxic  disease,  viz.,  rapidly- 
appearing  prostration,  high  fever,  profuse  diarrhea  and  vomiting. 
It  occurs  in  the  very  hot  weather. 

Pathology. — It  is  surprising  that  a  condition  giving  rise  to 
such  severe  symptoms  will  result  in  so  little  gross  pathologic 
changes.     No  constant  changes  are  found  in  any  organ.     The 


DISEASES   OP   THE   DIGESTIVE    SYSTEM.  267 

intestines  are  collapsed  and  show  a  pale  washed-out  appearance 
with  a  denudation  of  the  superficial  epithelium.  The  thin  in- 
testinal contents  have  a  yellow  color  and  musty  odor. 

Symptoms. — This  is  usually  not  a  primary  disease  occurring, 
as  a  rule,  during  the  convalescence  from  an  acute  gastroenteric 
disorder.  There  is  usually  sudden,  violent  and  profuse  vomiting, 
at  first  the  contents  of  the  stomach  followed  by  a  fluid  vomitus 
and  considerable  retching.  A  diarrhea  soon  follows,  fecal  in 
character  at  first,  the  discharges  soon  becoming  entirely  fluid, 
soaking  through  napkins  and  protecting  cloths  as  soon  as  passed. 
They  occur  very  frequently,  every  half  hour  or  oftener,  have 
a  musty  or  foul  odor,  and  are  practically  colorless.  But  little 
mucus  is  passed  as  a  rule. 

There  is  a  rapid  wasting,  the  skin  is  cool,  pale  and  transparent, 
and  soon  becomes  wrinkled  from  the  wasting;  eyes  are  sunken 
and  rolled  up ;  the  child  lies  at  first  listless  and  takes  no  notice 
of  its  surroundings.  The  temperature  rises  rapidly,  reaching 
103°  F.  to  105°  F.  or  106°  F.  in  a  short  while.  Rarely  cases 
may  be  seen  in  which  the  temperature  does  not  rise  much  above 
normal,  if  at  all,  and  it  is  in  these  that  the  prognosis  is  so  much 
graver.  The  pulse  is  feeble,  rapid  and  without  volume,  the 
respirations  are  hurried  and  shallow,  the  tongue  is  at  first  coated 
but  later  is  denuded  of  epithelium  and  becomes  red  and  dry.  The 
abdomen  is  retracted ;  the  urine  scanty ;  the  fontanelle  depressed ; 
there  is  great  thirst  but  water  is  usually  vomited  at  once  after 
swallowing.  Later  there  may  be  a  shrill  cry  which  is  suggestive 
of  meningeal  irritation. 

Prognosis. — The  prognosis  is  grave  in  all  cases  of  cholera 
infantum,  no  matter  how  slight  they  may  appear  to  be  in  the 
beginning. 

The  duration  is  short,  improvement  either  being  very  prompt, 
or  a  fatal  termination  inevitable  in  24  or  48  hours.  Excessively 
high  or  a  very  low  range  of  temperature  are  grave  signs.  Some 
infants  die  within  12  hours  in  spite  of  early  and  scientific  treat- 
ment. 

Diagnosis. — No  other  condition  met  with  in  the  gastrointes- 
tinal disorders  in  children  presents  so  severe  a  picture  of  serious 
illness.     The  association  of  severe  vomiting,  profuse  diarrhea, 


268  THE   DISEASES   OP    CHILDREN. 

rapid  wasting,  high  temperature  and  prostration  is  sufficient  for 
a  diagnosis. 

Treatment. — The  indications  for  treatment  are  very  positive, 
viz.,  to  withhold  all  food,  clearing  out  of  the  stomach  by  stomach 
washing,  and  the  bowel  by  purgation  and  enteroclysis,  anti- 
pyretic measures,  baths  or  packs.  If  the  wasting  diarrhea  keeps 
up,  the  indication  is  very  positive  for  the  hypodermic  admin- 
istration of  morphia  and  atropia.  Give  morphia  in  dose  of 
1/100  grain  to  child  of  one  year  and  repeat  for  its  effect. 
Atropia  can  be  given  in  1/600  grain  and  repeated  as  indicated. 

Enteroclysis  and  hypodermoclysis  are  indicated  to  renew  the 
fluids  lost  in  the  profuse  watery  diarrhea.  Hydrotherapy  should 
be  used  for  the  pyrexia,  putting  the  child  in  the  water  at  100°  F. 
and  cool  gradually  to  85°  or  90°  F.,  being  careful  to  use  friction 
of  extremities  and  body  while  in  the  water.  Cold  compresses 
should  be  applied  to  the  head  and  renewed  at  frequent  intervals 
during  the  bath.  If  the  temperature  is  below  normal  hot  water 
should  be  added  to  the  bath  to  110°  F.  The  baths  should  be  pro- 
longed for  at  least  5  minutes.  The  addition  of  mustard  to  the 
bath  water  is  beneficial.  Antipyretic  drugs  should  not  be  used 
under  any  circumstances.  If  stimulation  is  needed  it  should 
be  used  hypodermatically,  as  it  is  not  safe  to  rely  upon  the  stom- 
ach for  absorption.  No  drug  will  give  quicker  results  than 
camphor  dissolved  in  olive  oil,  gr.  xx  to  '§i,  and  of  this  solution 
giving  10  or  15  minims  hypodermatically.  The  effect  of  cam- 
phor is  quick  but  transitory,  and  should  be  repeated  or  supple- 
mented by  brandy  or  digitalis  or  strophanthus,  1  or  2  minims 
of  the  tincture  of  either  preparation  with  the  brandy. 

No  food  should  be  given  by  the  mouth  until  all  nausea  and 
vomiting  have  ceased  and  the  diarrhea  is  cheeked.  Small  quan- 
tities of  sterile  water  can  then  be  given,  2  teaspoonfuls  at  a  time 
every  15  or  20  minutes,  and  usually  this  is  taken  ravenously. 
If  retained  a  small  quantity  of  dextrinized  barley  can  be  given 
to  which  has  been  added  a  few  drops  of  brandy  or  a  small  quan- 
tity of  panopepton  or  peptonoids.  If  the  child  soon  tires  of 
barley  water,  gruels  made  from  the  other  cereals  can  be  tried, 
rice,  granum,  wheat  flour,  etc.  Later  the  animal  broths  can  be 
tried,  then  whey,  to  which  later,,  skimmed  milk  can  be  added, 


DISEASES    OP    THE    DIGESTIVE    SYSTEM.  269 

after  boiling  the  whey.  The  milk  should  best  be  pasteurized  at 
first.  A  rise  in  temperature  with  a  return  of  the  diarrhea  or 
vomiting  after  the  resumption  of  a  milk  feeding,  is  evidence 
enough  that  the  milk  should  be  discontinued  at  once,  and  a  pur- 
gative given  to  wash  out  the  undigested  masses  and  the  same 
routine  again  begun. 

Tf  the  same  experience  is  encountered  on  again  giving  cow's 
milk,  condensed  milk  should  be  tried,  as  this  is  low  in  fat  per- 
centage, and  often  can  be  taken  care  of  when  modified  cow's 
milk  cannot. 

The  termination  of  the.se  cases  is  either  in  prompt  recovery, 
early  death  or  a  development  of  a  severe  enterocolitis. 

ACUTE  ENTEROCOLITIS. 

Synonyms. — Ileocolitis;  dysentery;  enteric  infection;  inflam- 
matory diarrhea  and  enteritis. 

In  this  condition  there  are  more  or  less  severe  changes  occur- 
ring in  the  intestinal  mucous  membrane,  usually  without  in- 
volvement of  the  stomach. 

Etiology. — This  trouble  is  rarely  primary,  following,  as  a 
rule,  upon  some  one  of  the  acute  forms  of  gastric  or  gastrointes- 
tinal disorders. 

The  Shiga  bacillus  is  very  often  found,  also  the  colon  bacillus 
and  streptococcus.  Age  plays  an  important  part  in  the  etiology. 
It  is  most  frequent  during  the  second  year,  or  the  much-dreaded 
"second  summer,"  not  because  the  teeth  are  being  cut  at  this 
time  but  because  the  child  is  allowed  to  eat  a  too  liberal  diet 
during  this  period  and  acute  gastrointestinal  troubles  follow. 
It  may  complicate  the  acute  exanthemata  or  pneumonia.  Bottle- 
fed  babies  are  prone  to  develop  this  condition.  Bad  hygienic 
conditions  predispose  to  its  development  as  do  the  nutritional  dis- 
orders, rachitis,  scorbutus,  and  tuberculosis. 

Pathology. — As  implied  by  the  name  given  this  trouble,  the 
process  is  limited  largely  to  the  colon  and  the  lower  portion  of 
the  ileum,  in  a  small  percentage  only  the  colon  may  be.aft'ected. 
The  stomach  may  show  signs  of  catarrhal  inflammation  but  as  a 
rule  is  normal.  Three  grades  are  usually  described,  the  mild, 
or  acute  catarrhal;  idcerative;  and  pseudomembranous. 


270  THE  DISEASES  OF   CHILDREN. 

1.  Catarrhal,  One  is  impressed  with  a  condition  seen  at 
autopsy  in  fatal  cases  of  catarrhal  enterocolitis,  viz.,  the  com- 
paratively slight  changes  seen  macroscopically  in  the  intes- 
tines. The  stomach  and  upper  part  of  the  small  intestine  will 
show  changes  varying  from  a  very  slight  congestion  here  and 
there,  with  small  amounts  of  mucus  loose  in  the  bowel,  or  bath- 
ing the  surface  of  the  mucous  membrane,  to  a  deeply-congested 
area  at  frequent  intervals.  The  deeply-congested  areas  are 
found  at  or  near  the  cecum.  Pyer's  patches  are  swollen,  and 
the  general  surface  of  the  mucous  membrane  appears  granular. 
On  section  the  mucous  membrane  shows  a  loss  of  superficial 
epithelium  in  some  places  perhaps  approaching  the  ulcerative 
stage.  There  is  a  general  round-cell  infiltration  of  the  mucous 
membrane  causing  thickening  and  some  swelling  of  the  lymph 
nodes. 

2.  Ulcerative.  In  this  form  there  may  be  a  follicular  ulcer- 
ation, being  limited  to  the  solitary  follicles  or  a  coalescence  of 
a  number  of  these  forming  a  large  ulcerated  area.  The  ulcera- 
tion may  also  involve  a  large  area  and  be  of  a  catarrhal  variety 
entirely,  and  quite  superficial.  Ulcers  are  rarely  found  above 
the  lower  12  or  15  inches  of  the  ileum,  and  are  chiefly  located 
in  the  colon.  In  those  areas  where  the  follicles  have  coalesced 
the  destructive  process  is  deep,  penetrating  to  the  muscular 
coat,  but  in  the  milder  form  it  is  superficial.  The  mucous  mem- 
brane has  a  pitted  appearance. 

3.  Pseudomembranmis.  In  this  form  also  the  process  is 
chiefly  located  in  the  lower  ileum  and  most  of  the  colon.  There 
is  a  general  thickening  of  the  intestinal  wall,  due  to  round-cell 
infiltration,  congestion  and  attachment  of  the  pseudomembrane. 
The  whole  surface  of  the  colon  may  be  covered  with  membrane 
or  only  a  portion  of  it,  with  deeply-congested  areas  here  and 
there,  from  which  the  membrane  has  become  detached.  The 
process  is  rarely  found  in  patches,  but  it  may  be  limited  to  the 
extreme  lower  end  of  the  colon  and  the  rectum. 

The  pathological  changes  found  elsewhere  depend  entirely 
upon  the  complications  existing  during  the  attack.  It  is  not 
an  unusual  thing  to  have  a  patchy  bronchopneumonia,  especially 
in  the  prolonged  cases,  and  in  those  who  are  reduced  in  vitality, 


DISEASES    OF    THE   DIGESTIVE    SYSTEM.  271 

the  athreptic,  marasmic  child  being  much  more  liable  to  develop 
such  complications.  Nephritis  may  very  rarely  occur  as  a  com- 
plication. 

Symptoms. — Clinically,  it  is  often  very  difficult  to  differen- 
tiate the  three  varieties  of  this  condition  described  under  patho- 
logical changes.  I  have  seen  cases  with  a  large  number  of 
mucous,  bloody  stools,  with  other  symptoms  indicating  a  severe 
ulcerative  type,  in  which  the  autopsy  findings  did  not  reveal  any 
changes  usually  in  the  ulcerative  type. 

If  primary,  an  enterocolitis  usually  begins  suddenly,  with 
vomiting,  a  rise  of  temperature  varying  from  102°  to  104°  F., 
with  proportionate  increase  in  pulse  rate,  and  the  child  appears 
sick  from  the  onset. 

The  vomiting  as  a  rule  is  not  severe  or  often  repeated,  and  is 
soon  followed  by  abnormal  evacuations.  The  first  part  of  the 
first  stool  may  be  normal,  the  last  loose,  perhaps  containing 
undigested  food  and  mucus.  The  character  of  the  movements 
rapidly  changes,  they  are  frequent,  perhaps  averaging  once  an 
hour;  thin,  contain  much  mucus,  and  vary  in  color  from  a  very 
dark  yellow  to  many  shades  of  green.  Some  of  the  stools  may. 
consist  simply  of  glary  mucus.  They  may  or  may  not,  in  the 
severe  cases,  contain  blood  varying  from  a  few  streaks  in  the 
mucus  to  a  larger  quantity.  The  stools  will  change  in  color, 
after  being  passed,  and  when  a  napkin  is  examined  the  hour  it 
was  soiled  should  be  known.  After  standing  they  frequently 
become  very  green  in  color,  turning  from  a  light  brown  to  a 
very  much  lighter  shade  of  green.  Frequently  there  is  tenesmus 
with  each  stool,  the  rectal  mucous  membrane  may  protrude  as 
the  child  strains.  The  mother  will  often  state  that  water  or 
nourishment  of  any  kind  "passes  directly  through,"  meaning 
that  the  ingestion  of  anything  causes  peristalsis  and  a  move- 
ment results.  If  there  is  much  toxemia  and  high  temperature 
the  child  will  probably  lie  in  a  stupor ;  with  a  lower  temperature 
it  is  apt  to  be  fretful  and  restless. 

It  is  not  infrequent  that  they  have  muscular  twitchings  or 
general  convulsions. 

The  high  range  of  temperature  is  usually  of  short  duration, 
there  being  an  elevation  of  2°  or  3°  F.  during  the  rest  of  the  acute 


272  THE   DISEASES   OP    CHILDREN. 

stage.  As  a  result  of  the  toxemia,  frequent  loose  actions,  long 
febrile  course  and  re.strieted  diet ;  there  is  rapid  wasting,  the  eyes 
become  sunken,  the  skin  is  wrinkted  and  the  fontanelle  sunken, 
the  picture  presented  being  anything  but  a  promising  one. 
Thirst  is  apt  to  be  a  prominent  symptom. 

Course  and  Duration. — The  duration  in  the  severe  form  of 
enterocolitis  is  usually  comparatively  short,  the  child  growing 
rapidly  worse  from  the  onset,  terminating  fatally  within  a  week 
or  10  days,  or  the  acute  symptoms  subside  and  the  convalescence 
is  prolonged  for  several  weeks,  or  an  improvement  follows 
promptly  from  the  acute  symptoms  and  the  child  succumbs  to  a 
complicating  bronchopneumonia. 

Cases  may  terminate  fatally  in  three  or  four  days,  in  spite  of 
diet  and  treatment. 

Milder  cases  are  more  often  seen,  but  the  general  symptoma- 
tology is  the  same,  a  less  abrupt  onset,  not  so  frequent  vomiting, 
fewer  stools,  but  they  have  the  same  general  characteristics,  nerv- 
ous symptoms  less  marked,  convulsions  unusual,  and  the 
general  duration  is  shorter.  The  acute  symptoms  usually  end 
in  about  a  week,  and  the  convalascence  while  slow  is  steady. 
Indiscretions  in  diet  result  in  very  frequent  relapses  and  a 
chronic  enterocolitis  is  the  natural  sequence.  This  is  especially 
true  when  milk  feedings  are  resumed  too  quickly  and  in  prescrip- 
tions too  rich  in  both  fat  and  proteids. 

Prognosis. — Several  factors  materially  influence  the  prognosis. 
The  younger  the  child  the  more  grave  the  prognosis;  severe 
attacks  under  six  months  are  usually  fatal. 

Artificially- fed  infants  bear  an  attack  poorly ;  in  the  athreptic 
and  poorly-nourished  the  results  are  poor;  cases  in  which  a  di- 
gestive disturbance  has  been  neglected  always  do  badly,  hence 
the  prognosis  is  decidedly  better  when  treatment  is  begun 
promptly. 

Treatment. — As  just  stated,  on  the  promptness  with  which 
treatment  is  instituted  in  these  cases  depends  in  a  great  measure 
the  results.  The  treatment  can  be  considered  under  four  heads ; 
1,  preventive  treatment;  2,  general  and  dietetic  treatment;  3, 
medicinal,  and  4,  hygienic  treatment. 

1.  Preventive.     Neglect    of    apparently     trivial     attacks    of 


DISEASES  OF  THE  DIGESTIVE   SYSTEM.  273 

gastroenteric  disturbances,  continuance  of  the  usual  diet  in  the 
presence  of  what  is  generally  considered  a  trivial  attack  of  vom- 
iting and  diarrhea,  is  responsible  for  more  of  these  cases  than 
any  other  cause,  and  undoubtedly  increases  the  mortality 
greatly. 

Mothers  should  be  educated  in  the  first  place  in  the  importance 
of  a  pure  milk  supply  in  the  artificially  fed,  the  value  of  absolute 
cleanliness  in  the  care  and  preparation  of  the  child's  diet;  the 
necessity  for  the  immediate  withdrawal  of  all  food  upon  the 
first  appearance  of  vomiting  or  an  abnormal  stool  and  early 
medical  treatment.  If  these  requirements  were  met  in  all  cases, 
the  frequency  of  the  severe  cases  and  the  mortality  would  be 
greatly  reduced. 

2.  General  and  Dietetic.  If  the  vomiting  is  recurrent  the 
stomach  should  be  washed,  using  warm,  filtered  and  boiled 
water.  If  on  a  general  diet  or  modified  or  whole  milk,  all  food 
must  he  withdrawn  at  once,  and  not  resumed  until  both  the  stom- 
ach and  intestines  have  had  a  rest,  and  then  resumed  very  grad- 
ually. The  first  food  given  should  be  a  dextrinized  plain  barley 
water  or  combined  with  any  of  the  animal  broths,  in  equal  parts, 
or  a  small  quantity  of  panopepton  or  liquid  peptonoids.  The 
latter  are  of  value  chiefly  because  of  their  alcohol  content,  having 
relatively  small  food  values.  Milk  can  be  resumed  after  the 
subsidence  of  the  symptoms  by  the  use  of  whey,  made  from  fat- 
free  milk,  combined  with  barley  water  or  a  diluted  fat-free  but- 
termilk made  with  a  pure  culture  of  lactic  acid  bacteria. 
Beef  juice  has  a  tendency  to  increase  the  diarrhea,  often  causing 
watery  movements.  The  food  must  be  changed  from  time  to 
time  also,  as  the  child  is  apt  to  become  tired  of  one  or  two  of  the 
combinations  mentioned.  If  it  refuses  food  entirely,  it  must 
be  given  by  gavage.  Do  not  resume  milk  feeding  too  suddenly ; 
add  1  or  2  drachms  of  skim  milk  to  a  barley-water  feeding, 
once  during  the  day ;  if  this  is  taken  care  of  give  the  same  quan- 
tity twice  the  next  day,  the  next  give  2  teaspoonfuls,  and  so  on, 
gradually  increasing  the  milk. 

A  valuable  agent,  but  a  much-abused  one  in  these  cases,  is 
colon  irrigation.  It  need  not  be  used  oftener  than  twice  in  the 
24  hours,  once  being  usually  sufficient;  a  soft  Nelaton  catheter, 


274  THE  DISEASES   OF    CHILDBEN. 

well  anointed,  should  be  used,  and  if  there  is  much  straining 
and  a  tendency  for  the  bowel  to  expel  the  tube,  the  irrigating 
bag  should  be  held  but  a  small  distance  above  the  buttocks.  If 
there  is  much  mucus  of  the  white,  glary  kind,  the  irrigation  can 
be  of  an  astringent  solution  to  advantage,  a  heaping  tablespoon- 
ful  of  tannic  acid,  dissolved  in  a  quart  of  water.  For  an  ordi- 
nary irrigation  use  the  normal  salt  solution,  using  not  less  than 
2  quarts  at  one  irrigation.  The  temperature  can  be  as  low  as 
85°  F,  in  febrile  cases,  or  95°  to  98°  F,  where  the  temperature 
is  not  so  high.  Tub  baths  are  given  for  cleansing  purposes  as  a 
routine,  but  should  be  repeated  as  an  antipyretic  measure.  Me- 
dicinal antipyretics  should  never  be  used, 

3,  Medicinul.  Shotgun  diarrheal  prescriptions  should  never 
be  given.  Only  such  drugs  should  be  used  as  there  is  a  special 
indication  for.  As  soon  as  the  first  symptoms  appear  a  purga- 
tive must  be  given,  castor  oil,  if  the  stomach  is  in  condition  to 
retain  it,  otherwise  calomel,  in  1  grain  doses  to  a  child  of  one 
year  or  over.  One  of  the  most  useful  is  bismuth  and  a  pure 
subnitrate  preparation  is  advised.  The  usual  dose  given  by 
the  average  practitioner  is  much  too  small.  It  should  be  given 
in  not  less  than  10  grain  doses  until  at  least  60  to  80  grains  have 
been  taken  in  24  hours.  It  is  a  valuable  agent,  acting  mechan- 
ically on  the  congested  and  inflamed  mucous  membrane.  An 
astringent  can  be  added  if  the  movements  are  very  frequent  and 
contain  much  mucus,  Tannalbin  or  tanningen  in  3  to  5  grain 
doses  can  be  added  to  the  bismuth  for  their  astringent  effect.  If 
there  is  much  odor  to  the  evacuations  salol  will  be  found  of  serv- 
ice, given  in  2  to  4  grain  doses  every  four  hours. 

Stimulation  may  be  needed,  but  should  be  reserved  for  active 
indications.  Hypodermatic  injection  of  strychnia  sulphate  gr, 
1/200  or  atropia  sulphate  gr,  1/400  may  be  given. 

Opium  is  of  service  in  those  cases  with  vQYy  frequent  move- 
ments and  a  great  deal  of  tenesmus.  Dover's  powder,  in  14=  to  1 
grain  doses,  is  a  valuable  remedy.  Opium  in  am-  form  should 
not  be  combined  with  a  prescription,  but  ordered  separately  and 
given  at  the  same  time  if  need  be.  This  is  important,  as  the 
opium  is  usually  the  first  remedy  to  be  discontinued.  Kerley 
has  recommended  the  addition  of  1  grain  of  sulphur  to  the  bis- 


DISEASES  OP  THE  DIGESTIVE   SYSTEM.  275 

niuth  preparation,  if  the  movements  do  not  turn  black  after  its 
administration  for  a  few  days.  For  the  tenesmus,  3  or  4  drops 
of  the  deodorized  tincture  of  opium  can  be  given  in  2  or  3 
drachms  of  starch  water  as  an  enema,  following  an  irrigation,  if 
the  Dover's  powder  is  ineffective. 

The  after-care  of  these  patients  is  most  important.  Medica- 
tion in  convalescence  is  not  specially  indicated,  as  they  usually 
respond  quickly  to  proper  diet  as  soon  as  it  is  safe  to  resume  it. 

4.  Hygienic.  In  no  class  of  cases  does  a  complete  climatic 
change  have  so  beneficial  an  action  as  in  children  convalescing 
from  enterocolitis.  From  points  south  of  Mason  and  Dixon's 
Line  no  other  change  is  more  beneficial  than  removal  to  points 
in  Michigan.  The  large  amount  of  water  through  this  State 
imparts  a  life-giving  something  to  the  air  which  works  wonders 
in  these  cases.  They  unquestionably  get  back  upon  a  gaining 
diet  much  quicker  in  this  climate  than  at  home.  Some  cases  do 
well  when  simply  moved  from  the  city  to  the  country  nearby — 
others  do  better  in  the  mountains  or  at  the  seashore. 

Great  care  should  be  exercised  in  keeping  the  soiled  napkins 
clean.  They  should  be  boiled  daily.  In  institutions  the  nap- 
kins from  the  well  should  be  treated  separately  from  the  in- 
fected ones.  These  cases  should  be  isolated  in  hospitals  and 
institutions,  and  not  too  many  kept  in  a  ward  or  room.  Their 
feeding  utensils  should  be  kept  apart  from  the  general  supply 
and  frequently  boiled. 

If  in  in.stitutions  but  few  should  be  put  in  the  same  ward, 
allowing  plenty  of  air  space  to  each  infant. 

CHRONIC  ENTEROCOLITIS. 

Synonym. — Chronic  Gastrointestinal  Indigestion. 

Acute  enterocolitis  frequently  ends  in  the  chronic  form.  The 
acute  symptoms  subside,  or  perhaps  the  child  shows  a  decided 
improvement,  it  is  fed  indiscreetly,  and  a  second  attack  follows, 
which  lapses  into  the  chronic  form.  It  is  found  in  hospital 
eases  of  acute  form  which  have  improved  and  been  allowed  to 
return  to  unhygienic  homes  and  bad  food,  with  the  chronic  con- 
dition following. 

It  may  be  seen  at  any  age  of  childhood,  an  inflammation  of 


276  THE   DISEASES   OF    CHILDREN. 

the  colon  alone  being  more  frequent,  however,  in  older  children. 

Pathology. — There  is  usually  a  catarrhal  inflammation  of 
the  mucous  membrane  of  the  colon,  and  the  last  10  or  12  inches 
of  the  ileum.  The  inflammatory  condition  extends  into  the 
tubular  glands  and  many  of  these  are  destroyed  by  pressure. 
There  may  rarely  be  an  ulceration  of  the  mucous  membrane. 
The  mesenteric  glands  are  enlarged. 

The  most  frequent  complication  in  this  form  of  trouble  is  a 
pneumonia,  hence  we  find  the  lungs  involved  to  various  degrees, 
from  a  hypostatic  condition  to  consolidations  here  and  there 
through  the  lung,  of  the  bronchopneumonia  type. 

Symptoms. — The  chief  general  symptom  is  a  more  or  less 
rapid  and  progressive  loss  of  weight,  with  abnormal  evacuations 
numbering  6  to  10  in  the  24  hours,  or  there  may  be  twice  as 
many.  The  stools  are  abnormal  in  color,  content  and  consis- 
tency. They  may  be  mushy  and  be  composed  mostly  of  a 
greenish  mucus,  or  they  may  lose  all  color  and  be  light  and 
contain  pus.  They  may  or  may  not  contain  blood,  usually  do 
if  there  is  much  straining.  The  color  varies  from  a  yellow  to  a 
brown,  with  all  shades  of  green.  If  on  milk  or  a  general  diet, 
curds  and  undigested  food  are  present. 

The  child  quickly  develops  into  that  condition  known  as  ath- 
repsia  or  malnutrition,  it  emaciates  quickly,  its  abdomen  is 
distended,  it  is  restless,  fretful  and  cries  a  good  deal,  the  fon- 
tanelle  is  depressed,  skin  wrinkled,  and  it  soon  develops  the  old- 
man  facies,  with  tightly-drawn  skin  over  the  face.  It  lies  upon 
its  back  or  side  with  legs  drawn  up,  the  skin  of  the  legs  and 
arms  is  in  folds,  and  there  is  no  subcutaneous  fat.  The  tem- 
perature is  below  normal,  and  may  reach  but  95°  F.  in  the  rec- 
tum. Owing  to  the  many  discharges  the  skin  of  the  buttocks 
may  show  an  intertrigo,  or  at  least  a  severe  redness.  Food  will 
be  generally  taken  with  greediness.  The  pulse  is  weak,  the  feet 
and  hands  cold.  Occasionally,  shortly  before  death,  the  feet 
and  hands  may  be  quite  swollen. 

Diagnosis. — The  chief  trouble  to  be  differentiated  is  from 
tuberculosis,  and  in  the  absence  of  marked  intestinal  disturb- 
ance this  may  be  difficult.  In  those  cases  which  have  a  distinct 
tubercular  family  history,  and  in  certain  hospital  cases  it  may 


DISEASES   OF   THE   DIGESTIVE   SYSTEM.  277 

be  more  puzzling.  It  probably  cannot  be  positively  determined 
without  the  use  of  tuberculin  which  is  one  of  the  diagnostic 
methods  advised.  When  there  is  distinct  involvement  of  the 
chest  the  diagnosis  of  tuberculosis  is  easier. 

Prognosis. — This  is  universally  bad.  While  some  cases  may 
show  an  improvement  even  after  several  weeks  of  an  apparently 
hopeless  condition,  the  majority  succumb.  The  prognosis  is  in- 
fluenced by  the  age,  surroundings,  intelligence  of  mother  or 
nurse,  and  feeding.  The  prognosis  in  children  under  one  year 
of  age  is  very  grave. 

Treatment. — 1.  Hygienic.  Fresh  air  and  a  change  of  cli- 
mate, if  possible,  is  of  prime  importance.  The  remarks  on  page 
275  relating  to  climatic  change  in  the  treatment  of  acute  en- 
terocolitis is  true  in  the  chronic  form.  If  thoroughly  pro- 
tected from  exposure,  the  child  should  be  out  of  doors  almost 
continuously.  Regular  baths  should  be  given,  but  without  ex- 
posure. As  described  in  the  previous  section  the  napkins  should 
be  carefully  washed,  and  the  child  changed  promptly  when  one 
is  soiled.  An  abdominal  binder  should  be  worn  in  addition  to 
the  shirt.  The  binder  in  the  form  of  the  sleeveless  shirt,  made 
with  shoulder  pieces  and  tapes  in  front  and  back  to  pin  to  the 
napkin,  is  best.  Stockings  should  always  be  worn  and  flannel 
skirt  also. 

2.  Dietetic.  In  no  other  condition  are  precise  instructions  in 
regard  to  feeding  so  necessary.  Written  directions  as  to  choice, 
mode  of  preparation,  time,  temperature  and  quantity  of  the  food 
should  be  given  the  mother.  The  diet  should  be  concentrated, 
leaving  little  residue.  The  digestive  capacity  for  carbohydrates, 
fat  and  proteid  is  much  enfeebled,  and  food  within  reach  of  the 
digestive  capacity  should  be  given.  Fat-free  whey ;  animal 
broths  with  fat  removed ;  dextrinized  cereals ;  predigested  milk, 
when  it  can  be  borne,  are  the  foods  w'hich  can  be  tried.  If  one 
seems  to  cause  a  recurrence  of  the  condition  it  is  discontinued. 
Regularity  of  feeding  is  most  important,  not  oftener  than  every 
two  hours,  and  food  given  in  2  or  3  ounces  at  a  feeding.  Over- 
feeding is  greatly  to  be  feared.  If  the  child  shows  an  improve- 
ment eggs  can  be  added  to  the  list,  peptonized  milk,  lactone 
buttermilk,  scraped  beef,  etc.     A  gain  in  weight,  or  if  it  stops 


278  THE  DISEASES   OF   CHILDREN. 

losing  with  coincident  improvement  in  the  stools,  is  an  assurance 
the  child  is  improving. 

3.  Medicinal.  Castor  oil  at  the  onset  and  repeated  occasion- 
ally is  a  valuable  agent,  1  or  2  teaspoonfuls  to  an  infant  of  one 
year.  An  emulsion  of  castor  oil  containing  10  drops  to  a  dose 
is  frequently  beneficial.  If  not  retained  calomel  in  1  grain 
dose  should  be  given. 

The  same  directions  as  to  the  administration  of  opium  in 
the  acute  form  obtain  in  the  chronic.  It  should  not  be  com- 
bined with  any  other  prescription.  Dover's  powder,  in  %  to  1,4 
grain  doses,  or  paregoric,  10  or  15  drops,  are  the  best  prepara- 
tions. Bismuth  is  a  valuable  agent  and  can  be  given  plain  or 
in  combination  with  tannalbin,  if  an  astringent  is  needed,  and 
salol,  if  there  is  much  fermentation  and  odor  present.  Astring- 
ent injections  should  be  given  when  there  is  much  mucus,  other- 
wise a  colon  irrigation  of  normal  salt  solution,  under  the  same 
general  rules  as  mentioned  before. 

Stimulants  should  not  be  given  unless  there  is  a  decided  indi- 
cation for  their  use.  Cod  liver  oil,  internally,  is  of  great  service 
in  convalescence  when  tolerated  by  the  stomach,  and  frequently 
it  can  be  taken  when  no  other  fats  can  be  borne. 

CONSTIPATION. 

Constipation  is  a  symptom,  not  a  disease.  It  is  more  or  less  a 
relative  term,  but  it  exists  when  the  bowel  movements  occur  less 
frequently  than  is  ordinary;  when  it  is  accomplished  with  diffi- 
culty, when  the  fecal  matter  is  reduced  in  quantity,  and  is 
drier  than  normal.     This  is  a  common  affection  in  children. 

Etiology. — The  chief  cause  of  constipation  in  infancy  is  the 
conformation  of  the  colon,  especially  the  sigmoid  flexure.  Ow- 
ing to  the  shallow  infantile  pelvis  and  the  relatively  long  mesen- 
tery of  the  sigmoid,  this  portion  of  the  large  bowel  is  freely 
movable,  often  found  beyond  the  middle  line  of  the  abdomen. 
During  the  first  few  months  after  birth  the  descending  colon 
grows  at  the  expense  of  the  sigmoid  and  the  apparently  superflu- 
ous sigmoid  is  shortened.  Because  of  this  freely  movable  length 
of  colon  just  above  the  rectum,  it  acts  as  a  storehouse  for  fecal 
accumulations  and  is  with  difficulty  emptied.     Its  contents  move 


DISEASES   OF   THE  DIGESTIVE   SYSTEM.  279 

slowly  and  absorption  takes  place  readily,  causing  increased 
dryness  of  the  fecal  mass.  Added  to  this  is  the  distension  which 
comes  from  fermentation,  rendering  movement  less  likely  to 
occur. 

Constipation  beginning  soon  after  birth,  especially  when  asso- 
ciated with  vomiting  should  cause  pyloric  stenosis  to  be  sus- 
pected. The  fear  of  pain  caused  by  a  fissure  may  be  a  volun- 
tary cause  of  constipation. 

Late  in  childhood  after  typhoid  fever,  or  an  attack  of  appen- 
dicitis, constipation  is  probably  due  to  bands  of  adhesions  acting 
as  a  mechanical  cause  of  constipation. 

Dietetic  causes  of  constipation  should  be  carefully  consid- 
ered. A  deficiency  in  fat,  in  both  breast  and  modified  milk, 
with  a  relatively  large  proteid  percentage  is  a  cause.  Too  long 
continuance  of  a  milk  diet  in  late  childhood  and  the  absence  of 
mixed  food,  carbohydrates,  etc.,  may  also  act  as  a  cause.  Too 
little  water  in  both  the  artificially  and  the  breast  fed ;  prolonged 
use  of  a  Pasteurized  or  sterilized  milk  may  act  as  causes. 

Loss  of  muscular  tone,  such  as  follows  the  acute  exanthemata, 
typhoid  fever,  or  as  is  found  in  rickets  and  athrepsia,  is  a  fre- 
quent cause.  Failure  to  begin  with  regular  habits  and  encour- 
agement to  have  daily  evacuations  at  a  regular  time  will  cause 
constipation.  It  often  follows  an  attack  of  acute  enterocolitis, 
due  sometimes  to  the  too  prolonged  use  of  astringent  drugs  in 
the  treatment  of  the  acute  condition.  The  use  of  soothing  syr- 
ups, all  of  which  contain  opium,  for  the  cure  or  alleviation  of 
colic  is  a  potent  factor  in  the  development  of  chronic  con- 
stipation. 

Symptoms. — A  normal  number  of  evacuations  is  a  purely  rel- 
ative term,  for  what  is  normal  to  one  baby  is  not  to  another. 
One  child  may  be  entirely  normal  with  one  evacuation  and  an- 
other may  have  two  natural  daily  movements  and  be  uncom- 
fortable without  that  number. 

The  infant  will  normally  have  from  two  to  four  soft  move- 
ments ;  later  from  the  fourth  to  the  sixth  month  they  become 
less  frequent,  perhaps  only  two  a  day,  and  during  the  latter 
half  of  the  first  year  the  constipation  usually  begins.  It  will 
have  one  natural  action  a  day,  or  it  must  be  assisted  to  have 


280  THE  DISEASES   OF    CHn.DREN. 

that.  If  it  has  the  one  action  a  day  and  this  is  firm  and  hard, 
it  is  constipated. 

When  a  child  has  not  had  a  movement  for  one  or  two  days 
it  may  or  may  not  present  symptoms.  It  is,  however,  apt  to  be 
fretful  and  cross,  there  may  be  colic,  nearly  always  flatulency, 
with  distension  of  the  bowels. 

Occasionally  a  case  may  be  seen  which  has  passed  several 
large,  firm,  hard  movements  which  have  so  stretched  the  sphinc- 
ter muscle  as  to  cause  the  mucous  membrane  to  tear.  This  does 
not  heal,  and  a  fissure  of  the  anus  results.  Because  of  the  pain 
caused  by  a  movement  when  a  fissure  is  present  the  child  volun- 
tarily suppresses  an  action  of  the  bowels  and  will  not  sit  upon 
the  chair  or  vessel.  The  pressure  of  the  accumulated  fecal 
masses  in  the  rectum  causes  a  passive  congestion  of  the  hemor- 
rhoidal plexus  of  veins  and  hemorrhoids  result.  A  prolapsus 
of  the  mucous  membrane  may  also  occur  as  a  result  of  the  strain- 
ing. In  some  cases  as  a  result  of  acute  constipation,  especially 
when  previously  regular  actions  have  obtained,  there  may  be 
vomiting  with  a  slight  rise  of  temperature  of  2°  or  3°  F.  They 
are  restless,  cross  and  peevish,  have  little  appetite  and  sleep 
poorly. 

Prognosis. — This  is  variable,  depending  upon  the  cause,  age 
of  child,  duration,  presence  of  complications,  etc.  Usually,  how- 
ever, it  is  fairly  good  and  by  faithfulness  in  carrying  out  direc- 
tions will  good  results  be  had. 

Treatment. — The  chief  indication  is  regularity  in  obtaining 
evacuations  from  the  bowels.  As  early  as  six  montbs  the  child 
must  be  taught  to  use  the  chair  or  vessel.  It  should  not  be 
allowed  to  sit  too  long  upon  these,  because  of  the  tendency  to 
development  of  hemorrhoids.  If  there  is  no  inclination  in  15 
minutes  to  strain  and  assist  the  movement,  a  glycerine,  pencil 
suppository  or  small  amount,  8  or  10  ounces,  of  water  thrown 
into  the  rectum  from  a  fountain  syringe,  held  about  3  feet 
above  the  child  should  be  used.  In  using  the  syringe  it  is  well 
to  attach  a  soft-rubber  catheter  to  the  hard-rubber  syringe  tip 
in  order  to  avoid  injury  to  the  rectum  in  its  introduction.  This 
will  cause  the  child  to  strain  to  expel  the  suppository  or  water, 
and  an  evacuation  results. 


DISEASES   OF   THE   DIGESTIVE    SYSTEM.  281 

Endeavor  to  locate  the  cause  of  the  trouble.  If  it  is  dietetic, 
as  indicated  in  the  description  of  the  etiology,  correct  this.  If 
the  mother 's  milk  shows  by  an  examination  an  excess  of  proteids, 
have  her  eat  less  meat,  take  more  exercise  and  drink  more  water. 
If  the  child  is  on  modified  milk  increase  the  fat  content  in  the 
prescription,  or  if  the  age  will  permit,  begin  the  varied  diet 
and  increase  the  amount  of  water  taken.  The  average  child, 
whether  breast  or  artificially  fed,  is  given  too  little  water. 

The  use  of  dextrinized  gruels  is  of  service  as  a  diluent  when 
modified  milk  is  given,  especially  an  oatmeal  water  or  one  of  the 
flours  made  by  the  Cereo  Company,  Tappan,  N.  Y. 

Abdominal  massage  is  of  great  benefit,  beginning  the  rub- 
bing in  the  right  iliac  fossa,  extending  from  this  point  over  the 
course  of  the  colon.  This  should  be  done  with  the  child  upon 
its  back  upon  a  firm  mattress. 

In  the  athreptic  or  marasmic  infants,  especially,  and  to  others 
also,  the  administration  of  orange  juice  is  of  great  assistance  in 
this  condition.  The  juice  of  half  an  orange  can  be  given  twice 
a  day,  not  too  close  to  a  milk  feeding. 

In  children  after  the  second  year  good  results  are  obtained 
from  giving  mufiins  or  biscuits  made  from  whole  wheat  flour, 
plain  or  mixed  with  bran.  Cooked  fruits  are  of  value  also,  as 
stewed  prunes  and  apples.  Spinach  and  asparagus  can  be  given 
older  children  to  advantage. 

Medicinal.  Medicine  should  not  be  resorted  to  until  all  other 
means  of  treatment  have  been  exhausted.  Of  all  the  remedies 
suggested  for  constipation  cascara  sagrada  is  one  of  the  most 
serviceable.  It  can  be  disguised  by  aromatics  without  its  effi- 
ciency being  destroyed.  Almost  any  of  the  aromatic  prepara- 
tions can  be  used  to  advantage.  It  acts  as  a  tonic  to  the  intes- 
tinal musculature,  and  from  the  maximum  dose  (20  to  60  drops), 
if  used  in  connection  with  dietetic  and  other  measures,  can  be 
reduced  in  a  short  time  to  the  minimum  dose  (10  drops),  and 
then  discontinued.    • 

An  occasional  dose  of  calomel  is  of  benefit,  especially  when 
the  actions  are  yery  light  in  color.  Rhubarb  and  soda  can  often 
be  used  to  advantage  as  follows : 


282  THE   DISEASES  OF    CHILDREN. 

Ijl  Pv.  rhei  5iss 

Sodii  bicarbonat  5i 

Syr.  tolutan  ^i 

Aquae  destillatae  q.s.  ad  ^i" 
M.  ft.  Sol.     (Shake.) 
Sig.     One  teaspoonful  once  or  twice  a  day. 

Syrup  of  tamarinds  is  of  benefit  used  as  caseara,  1  or  2  tea- 
spoonfuls  at  a  dose,  at  bedtime,  usually  but  one  being  required. 

Sodium  phosphate,  plain  or  effervescent,  taken  in  the  morn- 
ing before  breakfast,  well  diluted,  in  certain  cases  is  of  benefit. 
Two  to  five  grain  doses  of  carbonate  of  magnesia  may  be  ef- 
fective. 

In  cases  in  which  there  is  an  impaction  of  the  rectum  and  sig- 
moid an  injection  of  first,  a  stimulating  enema  containing  a 
half  ounce  of  glycerine  and  of  Rochelle  salts  can  be  used.  If 
this  is  not  successful,  an  emulsion  of  6  ounces  of  fresh  ox  gall  in 
1  pint  of  warm  water  may  be  effectual,  or  the  injection  of  6 
ounces  of  molasses  and  enough  milk  to  make  a  pint  may  be 
tried. 

Phenolphthalein,  in  14  to  1  grain  doses,  may  prove  efficacious 
if  other  remedies  fail. 

DILATATION  OF  THE  COLON.^ 

Synonyms. — Congenital  idiopathic  dilatation  of  the  colon; 
Hirschprung's  disease;  giant  colon;  Myu's  disease;  mega  colon. 

Etiology. — This  is  a  congenital  condition.  Those  cases  de- 
scribed in  adult  life  (pseudomega  colon)  are  believed  to  be  de- 
layed development  of  the  congenital  type  or  another  condition 
entirely,  due  to  aggravated  constipation. 

A  number  of  theories  have  been  advanced  as  to  the  etiology 
of  this  condition,  none  of  which  are  convincing.  The  following 
have  been  suggested  as  causes:  A  neuropathic  dilatation  and 
hypertrophy;  increased  length  of  the  colon;  a  valve  formation 
in  the  intestine ;  spastic  contraction  of  the  sphincter  ani ;  ab- 
normally long  mesentery  of  the  colon;  chronic  colitis,  etc.,  etc. 
Boys  seem  more  often  affected. 


1  T   am   indebted   to  the   excellent   ai-ticle   of  Dr.   J.    M.   T.   Finnev.   upon   this   subject 
in  Surgery,    Gynecology   and   Obstetrics,   June,    1908,   for  much  data   in   this   section. 


DISEASES   OP   THE   DIGESTIVE   SYSTEM. 


283 


Pathology. — The  process  in  the  majority  of  cases  is  limited  to 
the  sigmoid  flexure.  The  diameter  of  the  dilated  portion  may 
reach  6  or  8  inches,  and  it  fills  most  of  the  cavity.  The  walls 
show  dilatation  and  hypertrophy.  The  mesocolon  is  thickened 
and  of  irregular  lengths.     The  blood  vessels  and  lymphatics  are 


I^:^ '_____    .__     ■l:'i-*-r^..'^?>•- 
Fig.  50. — Mucosa  normal  colon.      x  300. 

much  dilated.  The  mucous  membrane  is  thickened,  congested 
and  occasionally  ulcerated. 

Microscopically  the  mucous  membrane  shows  chronic  inflam- 
mation. The  circular  muscular  layer  is  enormously  thickened, 
and  the  serous  coat  thickened  with  enlarged  lymphatics  and 
blood  vessels. 

Sjonptoms. — Enlargement  of  the  abdomen,  the  most  prominent 
symptom,  associated  \A\h.  obstinate  constipation,  is  present  early 
in  life.  The  large  abdomen  may  be  noticed  at  birth,  but  the 
child  may  be  several  months  old,  perhaps  several  years  before 
the  condition  becomes  very  marked.  The  abdomen  is  then  enor- 
mous, the  distension  of  the  colon  being  due  to  gas  and  feces. 
History  of  a  long  period  between  evacuations  of  the  bowels  may 
be  obtained,  one  case  reported  as  three  months. 


284 


THE   DISEASES   OF    CHILDREN. 


The  skin  is  harsh  and  dry,  complexion  pasty,  abdominal  wall 
thin,  through  which  peristaltic  waves  can  be  seen ;  the  veins  of 


1:  '  ■  %r^. 


-'-• -'V-'^'J/ 


'.bW«ll'5rl\ripl 


mucc»« 


Fig.   51. — Mucosa  giuiil  colon.       X  370. 


the  skin  are  distended.     Tympanites  is  quite  general  over  the 
abdomen,  the  liver  dulness  decreased. 

The  movements  from  the  bowel  are  apt  to  be  dry  or  putty 
like,  dark  in  color  and  offensive. 


DISEASES   OP   THE   DIGESTIVE    SYSTEM. 


285 


Fig.   52. — Congenital  idiopathic  dilatation  of  the  colon. 


Fig.    53.1 — Side   view   of   same   patient    as   Fig.   52. 


1  Figs.    50,    51,   52,   53   repi-oduced   through   the   courtesy   of  Dr.  J.   M.  T.  Finney, 
Baltimore,   from  Surgery,   Gynecology,   and   Obstetrics. 


286  THE   DISEASES   OF    CHILDREN. 

Dyspnea  may,  late  in  the  trouble,  be  quite  marked,  and  bron- 
chitis and  pneumonia  may  be  present.  Atelectasis  may  be  found 
in  the  lower  portion  of  the  lung.  The  pulse  may  be  irregular. 
A  cone-shaped  dilatation  of  the  bladder  has  been  noted.  The 
course  of  these  cases  is  essentially  chronic.  There  is  an  apa- 
the'tic  condition. 

Diagnosis. — Meteorism  and  chronic  obstipation  are  the  two 
symptoms  practically  always  present.  It  must  be  diagnosed 
from  tubercular  peritonitis,  volvulus,  carcinoma  of  the  in- 
testine. 

Prognosis. — ^While  not  fatal  directly,  the  complications  pres- 
ent may  bring  about  death.  Pulmonary  heart  and  digestive  dis- 
turbances may  result  fatally. 

Treatment. — This  is  either  surgical  or  medical.  Surgically, 
the  following  procedures  have  been  suggested:  Puncture  of  the 
intestine  (under  no  conditions  to  be  done)  ;  colotomy,  with  evac- 
uation of  the  contents  and  closure;  colostomy;  eolopexy;  enter- 
oanastomosis ;  resection  of  affected  portion  and  enteroanasto- 
mosis. 

Medically,  the  following  measures  have  been  suggested: 
Cathartics,  enemata,  massage,  electricity,  tonics,  exercise,  diet, 
etc.  The  mortality  rate  is  given  as  follows:  "Surgical  treat- 
ment has  a  mortality  rate  two-thirds  that  obtained  by  medical 
measures  and  a  recovery  rate  almost  three  times  as  great. ' ' 


CHAPTER  XIII. 

INTESTINAL  PARASITES. 

Intestinal  parasites  are  comparatively  infrequent,  yet  it  Ls  a 
common  belief  among  the  laity  that  every  child  which  picks  its 
nose  or  grits  its  teeth  at  night  is  affected  with  them.  Because 
of  this  deep-rooted  belief  the  subject  is  of  considerable  impor- 
tance. Among  the  facts  elicited  in  regard  to  the  child's  history 
is,  that  it  has  been  given  some  "worm  medicine"  before  the 
physician  has  been  consulted. 

Intestinal  parasites  are  not  seen  in  very  young  infants,  but 
are  found  in  children  after  a  mixed  diet  is  given,  or  after  it 
crawls  around  on  the  floor,  putting  things  in  its  mouth  picked 
up  from  the  floor. 

Varieties. — The  following  intestinal  parasites  are  found  in 
children:  the  Nematodes;  the  pin- worm,  oxyuris  vermicularis, 
whose  habitat  is  chiefly  the  sigmoid  and  rectum;  the  round 
worm,  ascaris  Uimbricoides,  found  chiefly  in  the  small  intestine, 
and  often  in  the  stomach;  the  hook  worm,  the  ankylostomum 
duodenale  or  uncinaria  duodenalis,  as  the  name  implies,  found 
chiefly  in  the  duodenum ;  the  cestodes,  the  two  species  of  tape- 
worm, the  tenia  solium,  the  pork  worm  and  the  tenia  mediocan- 
ollata,  the  beef  worm. 

OXYURIS  VERMICULARIS. 

Synonyms. — Pin-ivorm;  threadworm;  seatworm. 

Description. — The  habitat  of  this  worm  is  chiefly  in  the  sig- 
moid and  rectum,  the  female  worm,  however,  being  found  near 
the  cecum.  The  worms  and  ova  are  passed  in  large  numbers,  in 
the  feces  and  when  entangled  in  masses  can  be  easily  seen.  In 
girls  the  vagina  may  become  infected  from  the  discharges.  They 
are  very  small  in  diameter,  the  female  the  longer,  about  10  or 
12  mm.  in  length,  the  male  5  mm.  The  ova  are  quite  small, 
symmetrically  oval  in  shape,  .05  by  .02  mm.  in  dimension. 

287 


288 


THE  DISEASES  OF   CHILDREN. 


The  mode  of  infection  is  by  means  of  fingers,  toys,  fruit  in- 
fected with  the  ova,  these  being  carried  to  the  cecum  in  the  food 
and  there  develop.     They  do  not  need  an  intermediary  host. 

Symptoms. — The  chief  symptom  is  the  intense  itching  of  the 
anus,  produced  by  the  worms  in  the  rectum.  The  child  is  very 
restless,  both  day  and  night,  and  is  constantly  scratching  about 
the  buttocks.  A  catarrhal  condition  of  the  rectum  may  ensue. 
If  they  migrate  into  the  vagina  a  vulvovaginitis  results.  Incon- 
tinence of  urine  may  occur  from  the  irritation  of  the  bladder. 
In  males  an  irritation  of  prepuce  may  result  with  swelling  and 


Fig.  54. — Eggs  of  oxyuris  vermicularis. 

pain  on  voiding.  The  skin  about  the  anus  and  buttocks  shows 
evidence  of  scratching. 

Diagnosis. — The  anus  and  stools  should  be  inspected  in  every 
case  of  pruritus,  and  if  carefully  done  the  worm  will  often  be 
found.  An  enema  should  be  given  and  the  water  returned  care- 
fully examined.  In  every  case  of  masturbation  the  presence  of 
J;hreadworms  should  be  suspected. 

I  had  under  observation  a  child  whom  I  had  previously  seen 
in  two  severe  attacks  of  enterocolitis,  with  large  Viuantities  of 
mucus  passed  for  a  long  period  of  time.  Upon  the  first  appear- 
ance of  mucus  in  the  movements  after  this,  I  was  notified.  In- 
spection of  what  was  thought  to  be  mucus  in  a  movement  proved 
to  be  a  mass  of  threadworms.  The  diagnosis  was  verified  by 
microscopic  examination.  In  this  case  the  worms  had  not  been 
present  long  enough  to  cause  any  symptoms. 

Treatment. — The  chief  reliance  in  the  treatment  of  these  cases 
must  be  had  in  the  use  of  injections  into  the  colon  through  a 


INTESTINAL   PARASITES.  289 

long  colon  tube,  as  the  habitat  of  the  worm  is  below  the  cecum. 
The  treatment  must  be  thorough  or  the  results  will  be  corre- 
spondingly poor.  First,  a  preliminary  dose  of  ol.  ricini,  3ii, 
should  be  given,  and  this  followed  by  a  high  cleansing,  saline 
enema,  of  not  less  than  3  pints.  After  this  solution  has  been 
allowed  to  pass  through  the  tube  and  with  the  child  on  the  vessel, 
the  tube  is  reinserted  and  an  injection  of  1  ounce  of  the  infusion 
of  quassia  and  15  ounces  of  the  normal  salt  solution  given  high, 
the  tube  quickly  withdrawn,  the  nates  compressed  and  the  child 
kept  quiet  so  this  injection  will  be  retained  for  at  least  an  hour, 
if  possible.  This  treatment  is  repeated  each  night  for  a  week, 
at  the  end  of  which  time  a  careful  examination  should  be  made 
of  the  stools,  microscopically  for  the  presence  of  ova. 

It  should  be  remembered  also  that  the  ova  become  attached 
to  the  skin  about  the  anus,  and  when  scratching  the  fingers  of 
the  child  can  become  infected,  and  they  in  turn  carry  the  ova 
to  the  mouth,  and  a  reinfection  takes  place.  Hence,  extra  pre- 
cautions should  be  taken  in  cleansing  the  nates  after  evacuations, 
and  the  constant  application  of  a  10  per  cent  boraeic  acid  oint- 
ment about  the  anus  and  skin  surrounding.  Care  must  be  taken 
also  of  the  napkins,  night  clothes  and  bed  clothes,  boiling  after 
each  removal. 

ASCARIS  LUMBRICOIDES. 

Synonym. — Bound  Worm. 

Descriptioii. — As  indicated  by  its  common  name,  this  worm  is 
round  and  smooth,  being  usually  from  4  to  12  inches  long,  and 
tapering  at  both  ends  to  a  point.  This  worm  is  perhaps  the  one 
most  frequently  seen  in  children.  The  female  is  nearly  twice 
as  long  as  the  male,  the  head  having  the  projections,  and  pro- 
vided with  fine  suckers  and  teeth.  The  tail  of  the  male  is 
turned  upward.  The  ova  are  round,  brownish  in  color,  slightly 
larger  than  the  ova  of  the  threadworm. 

There  may  be  only  one  worm  present,  but  usually  there  are 
several.  I  have  had  one  case  in  which  two  were  vomited  and  88 
passed  per  rectum. 

They  may  be  found  at  any  point  tributary  to  the  intestine ;  in 
the  stomach,  from  which  it  is  usually  vomited,  at  any  point  in 


290  THE   DISEASES   OP    CHILDREN. 

either  large  or  small  intestine,  in  the  appendix  and  the  gall 
duct  and  bladder.  They  may  coil  themselves  together  and  form 
a  mass  of  sufficient  size  to  cause  an  intestinal  obstruction. 

Symptoms. — Large  numbers  of  the  worms  may  be  present 
and  cause  no  symptoms.  The  child  mentioned  which  passed  88 
was  ill  with  malaria  with  high  fever,  worms  were  not  suspected 
until  the  first  one  was  vomited.  The  fever  acted  as  an  anthel- 
mintic on  the  others  as  they  passed  from  the  bowel  soon  after. 


Fig.   55. — Eggs  of  ascaris  lumbricoides. 

The  presence  of  an  eosinophilia  has  been  pointed  to  as  a  prom- 
inent symptom. 

The  vague  symptoms  referred  to  above  may  be  present,  but 
they  have  no  significance  as  a  diagnostic  aid  at  all,  being  caused 
entirely  by  other  pathologic  conditions.  The  first  symptom  is 
the  presence  of  the  worm.  The  symptoms  believed  to  be  com- 
mon by  the  laity  are  restlessness  at  night,  flatulency,  picking  at 
the  nose,  grinding  the  teeth,  headache  and  convulsions. 

Diagnosis. — As  intimated,  the  only  reliable  diagnostic  sign  is 
the  presence  of  the  worm,  either  vomited  or  passed  per  rectum. 
In  this  event  examination  of  the  feces,  microscopically,  will  re- 
veal the  ova  in  large  numbers. 

Treatment. — One  of  the  most  reliable  vermifuges  is  santonin. 
It  may  be  given  in  connection  with  calomel. 

IJ  Santonin 

Hydrargiri   cliloridi   mitis   aii   gr.   i 
Triturate  thoroughly.     Ft.   Cht.  No.  iv 

These  are  best  given  in  the  morning  before  breakfast,  the 


INTESTINAL   PARASITES.  29.1 

child  having  liad  a  very  light  supper  the  evening  previous.  This 
should  be  followed  by  a  dose  of  castor  oil  (5ss)  in  four  hours. 
On  the  second  day  following,  the  stool  should  be  examined  for 
the  presence  of  ova.  Toxic  effects  are  sometimes  obtained  from 
santonin,  hence  it  should  always  be  given  in  small  doses  and  if 
need  be  repeated. 

ANKYLOSTOMUM   DUODENALE. 

Synonyms. — TJncinaria  duodenalis;  Jiook  worm  disease. 

Description. — The  natural  habitat  of  this  worm  is  in  the  far 
south  countries,  but  it  occurs  with  fair  frequency  in  this  country 
in  the  Southern  States.  * 

In  1893  Blickhahn  ^  reported  a  case  in  St.  Louis,  and  in  1898 
Dabney  reported  a  case  in  New  Orleans,  and  Tebault  another 
in  the  same  city  a  year  later.  In  1902  Harris  claimed  that  a 
number  of  cases  of  anemia  in  Georgia,  Alabama  and  Florida 
were  due  not  to  malaria,  as  universally  believed,  but  to  un- 
cinariasis. 

Stiles  states:  1,  uncinariasis  is  pre-eminently  a  disease  of 
sandy  localities;  2,  infection  occurs  chiefly  in  rural  districts, 
but  this  is  true  simply  because  it  is  in  such  districts  that  less 
attention  is  given  to  the  disposal  of  fecal  matter  and  because 
more  people  in  such  localities  are  brought  into  contact  with  the 
soil;  3,  whites  are  more  often  and  more  severely  infected  than 
negroes ;  4,  infection,  as  a  rule,  takes  place  in  more  than  one 
member  of  a  family ;  5,  children  and  women  show  a  more  severe 
infection  than  men ;  6,  in  hot  weather  the  symptoms  of  the 
disease  are  exaggerated. 

The  embryos  may  exist  for  a  month  outside  the  body  and  de- 
velop in  a  host.  Pollution  of  the  soil  from  improper  disposi- 
tion of  the  feces  is  the  cause  of  its  dissemination.  It  is  seen 
in  dirt  eaters;  and  an  infection  can  occur  from  uncooked  food 
wliieh  is  taken  by  the  child.  The  majority  of  these  worm.s  are 
found  in  the  second  portion  of  the  small  intestine,  and  are  pres- 
ent in  large  numbers  as  a  rule. 

Symptoms. — The  symptoms  in  the  host  of  the  hook  worm  are 
believed  to  be  due  to  a  toxemia,  chief  of  which  is  a  profound 
anemia ;  the  subjects  are  thin  and  pale,  with  muddy  complexions, 


^  Dock:  Loc.  cit. 


292  THE   DISEASES   OF    CHILDREN. 

the  abdomens  protrude  and  they  have  no  endurance  and  tire 
easily.  There  is  palpitation  and  dyspnea,  headache  and  dizzi- 
ness are  often  present;  they  are  dirt  eaters  and  have  perverted 
appetites;  have  no  ability  to  acquire  knowledge  or  to  work. 
They  are  listless,  idle  and  shiftless.  Disobedience,  cunning, 
lying,  stealing  and  other  symptoms  ordinarily  attributed  to 
hysteria  are  seen.  The  bowels  are  constipated  and  what  is  passed 
is  often  blood  stained;  the  abdomen  is  often  much  distended. 
Hemoglobin  is  reduced  out  of  proportion  to  the  diminution  in 
red  cells.     Hemic  murmurs  are  heard. 

Diagnosis. — The  patient  presents  a  rather  typical  picture,  and 
the  diagnosis  can  be  confirmed  by  microscopic  examination  of 
the  stools  for  the  ova  or  the  parasite  can  be  seen  by  the  eye. 
The  ova  are  much  larger  than  a  red  blood  corpuscle,  and  have  a 
colorless  capsule.  The  parasite  is  half  an  inch  long,  size  of 
a  hat  pin,  and  one  end  hooked  back  on  itself.  Stiles  suggests 
the  blotting-paper  test  for  diagnosis,  about  an  ounce  of  fresh 
feces  are  placed  on  a  piece  of  white  blotting  paper  and  allowed 
to  stand  an  hour.  The  feces  are  then  removed  and  the  color 
of  the  stain  examined.  In  a  large  percentage  of  cases  of  uncin- 
ariasis the  color  is  reddish-brown  and  reminds  one  of  blood 
stain.     This  test  is  not  considered  reliable. 

A  second  test  is  a  therapeutic  one.  Thymol  is  administered 
and  the  parasites  are  fourfd  in  the  stools. 

Prognosis. — This  is  good  if  the  case  has  not  progressed  too 
far  and  the  anemia  too  profound. 

Treatment. — Snyder  ^  recommends  a  preliminary  dose  of 
magnesium  sulphate.  Thymol,  finely  triturated,  is  given  at 
4  p.  m,  and  at  8  a.  m.  the  following  morning  in  dose  of  from  5 
to  20  grains,  in  capsules,  on  an  empty  stomach.  This  is  re- 
peated at  10  o'clock  and  the  dose  of  magnesium  sulphate  given 
at  12  o'clock.  One  or  two,  perhaps  more,  courses  of  thymol  may 
be  heeded  to  control  the  condition. 

Nourishing  food  and  iron  tonics  are  given  too  for  the  anemia, 
one  of  the  best  of  the  latter  being  diastiron  in  teaspoonful  doses 
after  meals.  Nux  vomica  is  of  service.  The  children  should 
be  removed  from  school. 


*  Pediatrics,  December,  1908. 


INTESTINAL   PARASITES.  293 

CESTODES-TENIA. 

Synonym. — Tape-worm. 

Description.— The  life  history  of  the  tenia  is  the  ova,  the 
larva  and  the  mature  worm.     The  ova  are  passed  from  a  segment 


Fig.   56. — Eggs  of  tenia  solium. 


Fig.     57. — He;Kl    of     tenia    solium. 
(Magnified  eighteen  times.) 


Fig.    58. — Head    of   tenia    saginata. 
(Magnified  eleven  times.) 


of  the  mature  worm,  which  is  found  only  in  man  and  out  with 
the  feces.  The  egg  then  passes  to  the  alimentary  tract  of  an 
animal  (the  tenia  solium  in  the  hog,  the  tenia  saginata  in  the 
beef).  The  egg  develops  into  the  larva  or  embryo  which  pene- 
trates the  intestinal  wall  by  means  of  its  hook-like  processes, 
and  becomes  encysted  in  the  muscle  of  the  host,  there  to  remain 
until  set  at  liberty  when  eaten  by  man,  where  it  develops  in  his 
intestine  into  the  full-developed  worm. 


294  THE   DISEASES   OP   CHILDREN. 

The  Tenia  Solium  is  shorter  than  the  beef  worm,  measuring 
from  5  to  15  feet.  The  segments  are  shorter  and  narrower,  and 
the  head  quite  small.  It  is  provided  with  four  suckers,  and  a 
number  of  hooks. 

The  Tenia  Saginata  or  Mediocanellata  is  from  15  to  30  feet 
long,  and  consists  of  segments,  thick  and  yellowish-white  in 
color,  about  an  inch  in  length.  They  diminish  in  size  toward  the 
head,  which  has  four  suckers  upon  it. 

Symptoms. — These  are  vague  and  indeterminate.  The  diag- 
nosis can  in  the  majority  of  instances  only  be  made  by  recog- 
nizing the  segments  in  the  feces.  There  may  be  symptoms  of 
indigestion,  restless  sleeping  at  night,  perhaps  some  colicky  pains. 
Alternating  constipation  and  diarrhea  may  be  present,  nausea 
and  vomiting  may  also  occur.  However,  an  individual  may  be 
a  host  for  years  and  never  suspect  the  presence  of  the  worm 
until  a  segment  has  passed.     There  may  be  more  or  less  anemia. 

Treatment. — The  use  of  only  inspected  meat  and  meat  prop- 
erly cooked  will  serve  as  an  efficient  prophylactic.  Before  treat- 
ment is  begun  careful  instructions  must  be  given  that  no  passage 
from  the  bowel  must  be  had  except  on  a  vessel,  so  it  can  be 
closely  examined,  and  the  head  of  the  worm  found,  otherwise 
it  could  not  be  told  whether  the  case  was  cured. 

The  child  is  given  a  very  light  supper,  and  a  dose  of  castor 
oil.  Before  breakfast  the  anthelmintic  selected  is  administered, 
among  which  may  be  mentioned  oleoresin  of  male  fern;  pome- 
granate or  its  alkaloid,  pelleterine ;  kousso,  turpentine  and  pump- 
kin seed. 

The  oleoresin  of  male  fern  in  15  minim  doses  in  a  gelatin 
capsule  if  the  child  can  swallow  it,  otherwise  emulsion  every 
hour  until  four  doses  are  taken.  This  is  followed  by  a  dose 
of  citrate  of  magnesia  in  three  hours. 

Pelleterine,  while  efficient,  is  too  expensive  for  ordinary  use. 
The  following  prescription  is  suggested  by  Townsend: 

I^  Oleoresin  aspidii  3i 

Tincture  quillajae  f-B^s 

Syr.  aurantii  dulcis       £.3! 

Syr.  aurantii  q.s.  ad     f.3vii 
M.  ot  Sig.     Take  in  two  equal  doses. 


INTESTINAL  PARASITES.  295 

Turpentine  can  be  taken  in  an  emulsion. 

BL  01.  terebinthinae  3iis8 

Aq.  Menth.  pip  ^sa 

Mucil.  tragacanth  qs.     5" 
M.  ft.  Emuls. 
Sig.     One  teaspoonful  every  three  hours,  to  be  followed  by  one  or  two 
doses  of  castor  oil  a  day,  in  small  amounts. 


CHAPTER  XIV. 

SURGICAL  CONDITIONS  OF  THE  INTESTINES. 

APPENDICITIS. 

Definition. — This  is  an  inflammation  of  the  appendix  vermi- 
formis,  and  under  this  term,  on  account  of  the  inability  to  differ- 
entiate cases  clinically,  is  included  all  varieties  of  inflammation 
about  the  caput  coli. 

Etiology. — Typical  appendicitis  is  rarely  seen  in  early  in- 
fancy, and  but  very  rarely  under  five  years  of  age.  At  this  age 
and  until  puberty  the  appendix  being  relatively  longer  than 
in  the  adult,  and  with  a  larger  opening,  is  more  liable  to  develop 
inflammatory  conditions.  This  allows  freer  entrance  of  fecal 
matter  which  remains,  and  as  a  result  of  bacterial  invasion  and 
a  mild  catarrhal  inflammation  forms  the  nucleus  of  an  enterolith. 
The  younger  the  child  the  more  the  attack  differs  from  one  in 
an  adult. 

The  direct  cause  is  of  bacterial  origin,  the  colon  bacillus,  the 
streptococcus  and  typhoid  bacillus  being  most  frequently  re- 
sponsible. The  presence  of  intestinal  parasites  as  an  exciting 
cause  should  be  mentioned.  The  appendix  in  children  is  normally 
located  higher  in  the  abdomen  than  in  adults. 

In  the  child  subject  to  that  vague  condition  called  lymphatism, 
in  which  there  is  a  tendency  to  the  enlargement  of  the  lymph 
nodes  generally,  especially  of  the  tonsils,  appendititis  is  much 
more  liable  to  occur.  The  rapid  progress  of  appendicitis  in 
children  has  been  ascribed  to  the  abundance  of  lymphoid  tissue 
existing  in  the  child's  appendix.  It  has  been  suggested  that 
infection  by  the  bacillus  of  la  grippe  or  pneumonia  is  often 
responsible  for  the  lighting  up  of  an  acute  appendicitis. 

Pathology. — Four  forms  of  appendicitis  are  clinically  de- 
scribed: 1,  catarrhal;  2,  ulcerative;  3,  gangrenous;  4,  sclerotic. 

1.  Catarrhal. — In   this   form   the   mucous   membrane   of   the 

296 


SURGICAL   CONDITIONS   OF   THE   INTESTINES.  297 

appendix  is  swollen,  its  lumen  being  almost  if  not  entirely  oblit- 
erated. The  process  is  usually  more  severe  around  an  enterolith 
if  one  be  present.  The  mucous  membrane  exfoliates  and  the 
cavity  is  filled  with  broken-down  cells  and  mucus.  The  swelling 
is  usually  more  severe  at  the  intestinal  opening.  After  the 
subsidence  of  the  catarrhal  inflammation  the  mucous  membrane 
never  returns  to  a  normal  condition. 

2.  Ulcerative. — This  is  rarely  a  primary  condition,  the  ulcer- 
ative being  grafted  on  the  catarrhal  form.  The  ulcerative  proc- 
ess may  involve  a  few  small  areas  or  the  entire  mucous  mem- 
brane of  the  appendix.  In  those  eases  of  the  ulcerative  form 
in  which  there  have  been  two  or  three  attacks,  without  perfora- 
tion, and  which  finally  subside  and  apparently  get  well,  there 
remains  a  constricting  band  of  mucous  membrane  at  the  site  of 
the  most  violent  ulceration.  There  may  be  one  spot  where  the 
ulceration  is  more  severe  which  may  result  in  a  perforation. 
The  point  where  this  occurs  is  near  the  tip,  as  a  rule,  though  at 
the  site  of  the  enterolith  the  ulceration  may  be  so  severe  as  to 
result  in  a  perforation.  When  a  perforation  of  all  the  coats 
of  the  appendix  occurs,  it  may  result  in  a  general  peritonitis 
or  the  formation  of  an  abscess,  walled  off  from  the  general 
cavity. 

3.  Gangrenous. — In  this  form  the  inflammation  is  so  violent 
that  a  part  or  the  entire  appendix  sloughs  off,  causing  a  general 
peritonitis  or  a  localized  abscess,  as  in  the  perforative  or  ulcera- 
tive form. 

4.  Sclerotic. — This  results  from  a  chronic  inflammatory 
process  involving  a  portion  or  the  entire  organ.  As  the  inflam- 
mation subsides  there  is  at  its  site  a  formation  of  new  con- 
nective tissue  which  strangulates  the  normal  structure,  resulting 
in  a  replacement  by  fibrous  tissue. 

In  all  forms  but  the  last  there  may  be  a  mild  localized  peri- 
tonitis with  the  formation  of  small,  fine  cobweb  adhesions.  In 
the  latter  these  adhesions  may  be  present  as  a  result  of  the  pre- 
existing acute  process.  In  the  perforative  form,  without  a 
localizing  infiammatory  wall,  a  large  quantity  of  pus  rapidly 
forms  in  the  cavity.  This  is  usually  thin  and  yellowish,  and 
contains  large  flakes  of  plastic  lymph  or  fibrin. 


298  THE  DISEASES  OF    CHILDREN. 

Symptoms. — 1.  Catarrhal.  In  this  form  there  is  pain  referred 
to  the  right  side  of.  the  abdomen,  more  frequently  in  the  right 
iliac  region,  but  owing  to  the  long  mesoappendix  in  children  it 
may  be  nearer  the  umbilicus,  and  not  infrequently  in  the  hypo- 
gastric region  over  the  bladder,  the  epigastrium,  or  at  any  point 
from  the  liver  to  the  iliac  fossa.  No  dependence  can  be  placed  on 
the  statement  of  the  child  regarding  abdominal  pain  in  appendi- 
citis. This  is  associated  with  tenderness  over  the  site  of  the 
appendix,  and  quite  early  there  develops  a  rigidity  of  the  rectus 
muscle  over  the  affected  side,  this  guard  being  an  involuntary 
manifestation.  Rigidity  must  be  differentiated  from  voluntary 
spasm.  It  is  less  apt  to  be  present  in  the  catarrhal  form  to  any 
great  extent,  but  is  always  present  in  the  other  more  severe 
forms.  There  is  a  slight  rise  of  temperature  to  100°  or  101°  F., 
with  quickened  pulse  and  respiration,  and  vomiting  may  be  a 
prominent  symptom.  Diarrhea  or  constipation  may  be  present, 
more  often  the  former.  Painful  micturition  may  also  be  present. 
These  symptoms  may  be  so  slight  as  to  almost  escape  notice  and 
go  entirely  unrecognized,  being  of  short  duration  and  not  severe, 
and  perhaps  mistaken  for  an  ordinary  attack  of  colic. 

This  was  the  case  in  an  institution  child,  nine  years  old,  under  my  ob- 
servation, who  had  been  ill  for  a  few  days  with  an  abscess  at  the  root  of 
a  tooth,  relieved  by  extraction.  The  temperature  had  been  normal  for  two 
'  days  when  there  was  a  rise  to  102  3/5°  F.  I  was  again  called,  and  the 
closest  questioning  did  not  elicit  any  complaint  or  history  which  would  aid 
in  the  diagnosis.  No  complaint  had  been  made  to  the  infirmary  nurse.  A 
thorough  examination  was  then  made,  the  chest  was  negative,  and  on  pal- 
pation of  the  abdomen  a  distinct  mass  the  size  of  an  egg  was  found  in  the 
right  iliac  region,  and  an  appendiceal'  abscess  diagnosed.  This  was  con- 
curred in  by  the  surgeon,  and  the  child  operated  upon  within  four  hours. 
An  abscess  was  found  containing  fully  3  ounces  of  fetid  pus,  and  with 
great  difficulty  a  perforated  and  gangrenous  appendix  was  freed  from  the 
dense  adhesions. 

This  case  is  illustrative  of  the  class,  and  also  emphasizes  that 
institution  children  cannot  be  taken  as  a  guide  as  they  are  usually 
stoical  and  complain  much  less  than  children  in  private  families. 

Attacks  usually  recur  with  comparative  frequency,  each  one 
likely  to  be  more  severe  than  the  former.  When  there  is  a  his- 
tory of  frequent  preceding  attacks,  careful  palpation  may  reveal 


SURGICAL   CONDITIONS   OF   THE   INTESTINES.  299 

the  congested  and  swollen  appendix  through  the  thin  abdominal 
wall. 

2.  The  ulcerative  form,  as  a  rule,  presents  more  acute  and 
active  symptoms,  an  exaggeration  of  those  of  the  catarrhal  type. 
The  pain  is  more  severe,  the  patient  seems  sicker  from  the 
onset,  the  temperature  may  reach  103°  F.,  vomiting  is  recur- 
rent, great  pain  being  caused  by  the  retching;  the  tenderness  is 
located  over  the  appendix,  usually  at  a  point  midway  between 
the  umbilicus  and  the  anterior  superior  spine,  the  so-called 
McBurney  point.  The  bowels  are  more  often  constipated  than 
loose,  though  a  diarrhea  may  be  present. 

This  is  the  description  of  a  classic  case,  but  there  are  frequent 
anomalies  encountered.  Because  of  the  atypical  cases  the  diag- 
nosis, sometimes,  is  most  difficult,  and  again  practically  no 
symptoms  are  present  calling  attention  to  the  abdomen  until 
a  general  perforative  peritonitis  has  developed  and  the  child 
is  dangerously  sick. 

3.  In  the  performative  form  with  localization  of  the  abscess 
there  is  an  easily  palpable  tumor,  rigidity  of  the  right  rectus 
muscle,  high  temperature,  characteristic  attitude,  lying  upon  the 
back  with  legs  drawn  up ;  hurried,  shallow  respiration,  and  rap- 
idly forming  and  sometimes  severe  tympanites.  The  face  has 
an  anxious  expression,  and  the  pulse  is  small  and  rapid.  There 
may  be  sweats. 

The  blood  count  will  show  a  marked  leucocytosis  and  this 
may  be  a  decided  diagnostic  aid.  If  there  is  a  count  of  18,000 
or  more  leucocytes  the  diagnosis  is  usually  more  certain.  A 
steadily-increasing  leucocytosis  is  a  more  typical  picture  and  a 
worse  sign  than  a  single  examination  in  which  a  large  increase 
is  found. 

Cabot  states  that  mildest  and  severest  cases  show  no  leu- 
cocytosis. Catarrhal  appendicitis  is  rarely  accompanied  by 
leucocytosis.  A  low  count  (8,000  to  11,000)  means  a  mild 
case,  a  very  severe  ease  or  an  abscess  thorouglily  walled  off. 
When  a  leucocytosis  of  18,000  to  2.'3,000  is  maintained  for  a 
number  of  days,  it  usually  means  a  large  abscess  pretty  well 
walled  off.  Bloodgood  considers  that  "within  the  first  48  hours 
a  leucocytosis  of  18,000  should  be  considered  an  indication  for 


300  THE   DISEASES   OP    CHILDREN. 

operation,  especially  if  there  is  a  rising  leucocyte  count."  A 
persistent  low  leucocyte  count  is  generally  a  positive  indication 
for  operative  interference  when  taken  into  account  with  the 
othei*  clinical  signs. 

The  symptoms  of  the  gangrenous  form  are  practically  those 
of  the  ulcerative  type,  except  they  are  apt  to  be  quicker  in 
developing. 

4.  Sclerotic  appendices  present  most  constant  pain,  nagging 
in  character  and  are  accompanied  by  more  or  less  digestive  dis- 
turbance.    Palpation  reveals  tenderness  and  slight  rigidity. 

Diagnosis. — This,  as  a  rule,  is  not  very  difficult,  but  has  to 
be  made  from  a  pneumonia,  pleurisy,  especially  of  the  lower 
portion,  and  of  the  diaphragmatic  layer,  intussusception  and 
volvulus. 

The  most  frequent  mistake  in  diagnosis  would  be  in  mis- 
taking an  acute  appendicitis  of  mild  type  for  an  acute  indi- 
gestion or  colic. 

In  right-sided  pneumonia  the  characteristic  expiratory  grunt 
is  present,  dilation  of  the  alse  nasi,  redness  of  the  cheek  of  the 
affected  side,  and  the  characteristic  physical  signs,  as  well  as  a 
much-quickened  pulse  and  respiration  in  the  typical  ratio  of 
pneumonia,  and  higher  temperature.  It  must  be  borne  in  mind, 
however,  that  in  some  cases  of  tentral  pneumonia  there  may  be 
few  of  the  typical  pneumonia  symptoms  present.  Cough  may 
be  wholly  absent.  Morse  ^  stated  that  ' '  the  abdomen  has  been 
twice  opened  in  children  by  well-known  Boston  surgeons  for 
appendicitis,  when  the  trouble  was  lobar  pneumonia. ' ' 

Examination  of  the  chest  should  be  made  in  every  case  of 
suspected  appendicitis  in  a  child,  and  in  eases  of  grave  doubt, 
wait  until  developments  clear  up  the  diagnosis. 

In  a  diaphragmatic  pleurisy  there  may  be  more  difficulty  in 
making  a  diagnosis  as  the  physical  sign>s  of  pleurisy  are 
masked,  the  pain  is  apt  to  be  referred  downward,  and  there 
may  be  slight  rigidity  of  the  right  rectus  muscle.  The  restricted 
freedom  of  movement  of  the  chest  is  one  of  the  chief  signs. 

In  intussusception  the  early  presence  of  the  tumor,  which  is 
movable,  the  associated  vomiting,  of  stereoraeeous  type  if  ob- 
struction is  complete;  the  passage  of  bloody  mucus,  and  without 

'American  Gynecology   and   Pediatrics,  vol.   13,  p.   143,   1900. 


SURGICAL   CONDITIONS   OF   THE   INTESTINES.  301 

much  fever,  is  sufficient  to  make  the  diagnosis  of  this  condition. 
The  tumor  of  an  intussusception  may  be  felt  by  a  rectal 
examination. 

Prognosis. — Even  if  of  a  mild  catarrhal  type  attacks  are  apt 
to  be  recurrent.  Age  is  an  important  factor.  The  prognosis 
is  graver  the  younger  the  child  and  the  more  severe  the  type 
encountered.  In  the  acute  perforative  and  gangrenous  type  it 
is  especially  bad  and  a  guarded  prognosis  should  be  given  in 
every  case. 

Treatment. — In  no  case  of  appendicitis  should  the  pediatrist 
conduct  the  ease  without  the  advice  of  a  surgeon  who,  in  justice 
to  all  concerned,  should  be  called  early.  The  disease  is  essen- 
tially a  surgical  one,  and  in  the  majority  of  cases  an  operation 
is  indicated. 

If  appendicitis  is  even  suspected,  the  child  must  be  put  to 
bed,  put  on  a  starvation  diet  for  a  few  hours,  and  an  ice  bag 
applied  to  the  abdomen.  An  enema  should  be  given  promptly. 
Opiates  should  not  be  given  as  they  mask  the  symptoms  and  ren- 
der later  and  more  positive  diagnosis  difficult. 

If  the  ulcerative  type  can  be  diagnosed,  an  operation  should 
be  performed  early.  Kelly  gives  the  following  reasons  for  the 
early  operation,  during  the  first  24  hours:  "It  is  safest,  the 
operation  is  more  easily  done,  the  patient  is  spared  days  of 
suffering;  the  liability  to  recurrent  attacks  and  the  risk  of 
hernia  are  obviated." 

Richardson  ^  states  ' '  that  the  appendix  should  be  removed  in 
( 1 ) ,  all  severe  cases  seen  early,  unless  there  are  contraindications 
to  operation  in  other  organs  or  in  the  patient's  general  condi- 
tion; (2),  in  all  severe  cases  which  when  first  seen  are  at  a  stand- 
still or  are  increasing  in  severity;  (3),  in  all  cases  in  which  the 
symptoms  are  well  marked  and  well  localized;  (4),  in  all  severe 
cases  unless  they  are  unmistakably  improving;  (5),  in  those  cases 
in  which  the  disease  is  limited  to  the  appendix  itself,  and  it  is 
presumably  certain  the  abdomen  can  be  closed  without 
drainage. ' ' 

If  more  than  24  hours  has  elapsed  since  the  initial  symptoms 
the  operation  had  perhaps  best  be  postponed  until  later. 


^  Park's  Surgery. 


302  THE   DISEASES   OP    CHE^DREN. 

The  interval  oi)eration  is  indicated  in  recurrent  cases,  the 
mortality  in  these  being  nil. 

The  operation  in  a  child  is  usually  easier  than  in  an  adult. 
The  muscles  are  thinner  in  the  abdominal  wall  and  anesthesia 
relaxation  easier  produced.  The  operation  should  always  be 
quickly  performed,  as  the  time  element  in  the  production  of 
the  shock  is  very  great.  Because  of  the  need  of  stimulation, 
ether  is  the  best  anesthetic  to  be  used.  Care  in  its  administra- 
tion is  more  necessary  than  in  adults. 

Because  of  the  various  locations  of  the  appendix  in  the  child, 
no  special  incision  can  be  selected  for  all  cases;  it  should  be 
made  long  enough  primarily  in  order  not  to  be  obliged  to  lose 
time  by  enlarging  it  later.  Some  discretion  is  necessary  in  de- 
ciding whether  to  drain,  to  prolong  the  operation  looking  for 
the  appendix  in  gangrenous  cases,  etc. 

Postoperative  temperature  is  the  rule  for  a  day  or  two.  To 
combat  the  thirst,  saline  enemas  every  four  hours  should  be 
given  in  amounts  which  it  is  found  the  child  will  retain,  and 
water  by  the  mouth  as  soon  as  there  is  no  nausea.  Liquid  nour- 
ishment is  given  early. 

Opium  can  be  given  for  great  pain  and  restlessness.  Bromides 
may  be  used  in  the  less  severe  eases. 

INTUSSUSCEPTION. 

This  condition  is  an  obstruction  of  the  bowel  due  to  the  slip- 
ping of  one  segment  of  the  bowel  into  another.  When  one  sees 
the  large  number  of  postmortem  intussusceptions  in  one  case, 
it  is  a  wonder  it  is  not  more  often  encountered  in  the  living. 
Frequently  as  much  as  10  or  15  inches  of  the  small  gut  will  be 
found  invaginated  at  the  autopsy,  there  being  often  a  number 
of  these,  and  the  invaginations  are  easily  reduced. 

Pathology. — The  invagination  is  from  above  downward,  in 
the  direction  of  the  fecal  current.  There  are  three  layers  of 
bowel  at  the  tumor,  the  outer,  invaginating,  covering  or  re- 
ceiving layer  is  the  intuss^lscipiens,  the  inner  layer  the  intus- 
susceptum.  The  narrow,  constricted  end  is  the  neck.  The  neck 
is  very  frequently  the  ileocecal  valve,  and  several  feet  of  the 
ileum  may  pass  through  the  neck  into  the  colon. 


SURGICAL   CONDITIONS   OF   THE   INTESTINES.  303 

Etiology. — Two  theories  of  the  cause  have  been  presented,  tlie 
theory  of  spasm  and  of  paralysis. 

Wallace  ^  suggests  that  a  portion  of  the  bowel  is  damaged  by 
some  interference  with  its  blood  supply  and  bulges  and  may 
perforate,  and  that  the  intussusception  is  the  result  of  nature's 
effort  to  reinforce  the  weak  piece  by  splinting  it  between  healthy 
layers  of  intestinal  wall,  and  that  instead  of  being  the  cause  of 
the  trouble  the  invagination  supports  the  weakened  intestine. 

It  is  more  apt  to  occur  during  an  attack  of  acute  intestinal 
disorders  when  peristalsis  is  most  active.  The  relatively  long 
mesentery  of  the  bowel  in  infancy  and  the  thinness  of  the  bowel 
wall  has  been  given  as  a  cause.  It  is  rarely  seen  in  early  in- 
fancy, being  most  frequent  from  the  sixth  month  to  the  second 
year,  and  quite  rarely  after  this  j)eriod.  In  a  large  percentage 
of  cases  the  invagination  occurs  at  the  ileocecal  valve,  the  small 
intestine  slipping  into  the  colon,  the  large  intestine  literally 
swallowing  the  small,  though  many  occur  in  the  small  intestine. 
It  occurs  more  often  in  boys,  in  the  ratio  of  about  two  to  one. 

Quite  rarely  the  reverse  of  the  above  is  seen,  where  the  intus- 
susception will  be  a  segment  of  bowel  from  below,  telescoping 
into  the  intussuscipiens  above.  If  much  of  the  bowel  is  in- 
vaginated  owing  to  the  mesentery  being  attached,  the  tumor 
is  curved  on  itself,  because  the  mesentery  attached  to  the  bowel 
is  pulled  in  after  it. 

Owing  to  the  constriction  at  the  neck  and  engorgement  of  the 
intussusceptum,  pathological  changes  occur  quickly,  but  the  ex- 
tent of  these  depend  upon  the  length  of  time  which  the  condition 
has  existed.  If  it  has  existed  for  some  time  reduction  may  be 
impossible,  both  from  the  adhesions  formed  and  the  greater  en- 
gorgement of  the  apex  of  the  intussusception.  Only  one  thing 
can  occur,  if  enough  time  elapses,  viz.,  sloughing  of  the  intus- 
susceptum at  its  most  constricted  portion.  Adhesions  form  be- 
tween the  invaginated  layers,  and  as  inflammation  of  the  peri- 
toneum progresses  adhesions  of  coils  of  the  bowels  may  occur 
externally. 

Sjrmptoms. — The  onset  is  usually  sudden,  and  if  much  of  the 
bowel  is  invaginated  and  sudden  constriction  occurs,  the  onset 


*  Journal   American    Medical   Association,    April    11,    1908. 


304  THE   DISEASES   OF    CHILDREN. 

may  be  associated  with  some  shock.  Padn  is  a  prominent  symp- 
tom, sudden  and  violent.  The  child  cries  out,  draws  up  its 
legs  and  vomiting  shortly  begins.  Distension  of  the  abdomen 
is  soon  noted  and  the  child  will  soon  pass  blood  and  mucus 
from  the  rectum.  The  first  evacuation  may  be  fecal,  but  it  is 
soon  followed  by  blood  and  mucus.  This  is  one  of  the  char- 
acteristic symptoms.  There  is  usually  no  fever  at  the  onset,  in 
fact  the  temperature  may  be  subnormal,  and  its  elevation  indi- 
cates beginning  peritonitis,  but  the  respiration  and  pulse, 
especially  the  latter,  are  accelerated.  If  obstruction  is  complete 
the  vomiting  may  soon  become  stercoraceous  in  character,  us- 
ually not  occurring,  however,  until  late.  Later,  as  peritonitis 
develops  there  is  a  rise  of  several  degrees  in  the  temperature. 

The  child  has  an  anxious  expression,  in  fact  looks  sick.  The 
presence  of  a  tumor  in  the  abdomen  is  convincing  proof  of  the 
condition.  Through  the  thin  abdominal  wall  of  the  child  this 
can  usually  be  found,  unless  the  tympany  has  been  too  rapid  in 
forming.  As  the  intussusception  is  so  often  found  at  the  ileo- 
cecal valve,  the  tumor  is  most  often  to  be  found  on  the  right  side 
of  the  abdomen  between  the  right  iliac  region  and  the  right 
hypochondrium.  The  tumor  is  doughy  to  the  touch,  is  sausage- 
shaped  and  rounded.  The  child  may  be  so  sensitive  as  to  make 
palpation  of  the  abdomen  impossible.  In  many  cases  the  tumor 
or  intussusception  can  be  felt  through  the  rectum,  especially  if 
the  invagination  is  in  the  sigmoid.  Hiccough  may  be  present 
and  is  an  unfavorable  sign. 

The  duration  of  the  attack  varies  greatly.  The  attack  may 
be  so  acute  as  to  be  fatal  in  24  hours,  unless  the  diagnosis  is 
made  early  and  the  condition  relieved.  Other  cases  may  run 
on  for  four  or  five  days,  and  one  unusual  case  has  been  reported 
by  Snow  ^  of  Buffalo  in  which  a  seven-months '-old  child  suffered 
from  an  intussusception  for  16  days,  when  a  piece  of  gangrenous 
intestine  6  inches  in  length  protruded  from  the  rectum,  was 
ligated  and  removed,  recovery  following. 

Diagnosis. — The  chief  diagnostic  points  are  the  sudden  onset, 
great  pain,  acute  obstruction  of  the  bowel,  bloody-mucous  evac- 
uations, the  presence  of  the  tumor  in  the  abdomen,  absence  of 


'  Carr :   Practice  of  Pediatrics. 


SURGICAL  CONDITIONS  OF   THE   INTESTINES.  305 

fever  at  the  beginning,  the  continuous  vomiting  and  the 
tympany. 

There  is  a  train  of  symptoms  not  seen  in  any  other  condition, 
but  even  with  the  association  of  a  few  of  them,  an  intussuscep- 
tion should  be  suspected,  and  in  a  child  this  suspicion  becomes 
verified  if  a  sausage  tumor  is  felt  in  the  belly  or  the  invaginated 
gut  palpated  per  rectum. 

Prognosis. — This  is  necessarily  grave,  the  mortality  being 
over  60  per  cent  in  a  number  of  cases  reported  by  different  ob- 
servers. Prompt  operative  interference  offers  good  results. 
Temporizing  by  trying  this  or  that  mechanical  means  of  reduc- 
tion renders  the  prognosis  less  favorable,  if  operation  is  finally 
resorted  to.  Chronic  cases,  because  of  adhesions,  render  the 
operation  very  difficult. 

Spontaneous  cures  by  sloughing  off  of  the  intussusception  have 
been  recorded  but  they  are  rare,  and  cases  should  never  be 
neglected  by  waiting  for  this  result. 

Treatment. — The  only  safe  and  satisfactory  method  of  treat- 
ment is  surgical;  a  laparotomy  and  reduction  of  the  intus- 
susception by  slipping  out  the  invaginated  portion  of  the  gut. 
The  earlier  this  is  done  the  more  satisfactory  the  results.  The 
longer  the  operation  is  delayed  the  more  dangerous  it  becomes 
and  the  more  difficult  the  reduction  because  of  the  adhesions 
formed  between  the  layers  of  the  gut.  Reduction  may  be  impos- 
sible, rendering  resection  of  the  bowel  imperative.  This  is  nec- 
essarily a  very  serious  operation  in  an  infant. 

Owing  to  the  tendency  for  the  invagination  to  recur  at  the 
same  site  after  reduction,  the  mesentery  should  be  shortened  at 
the  time  of  operation.  Chloroform  should  be  the  anesthetic  of 
choice  during  operation. 

Palliative  methods  of  treatment  offer  less  than  the  operative, 
promising  practically  nothing.  The  ones  recommended  are  the 
inflation  of  the  bowel  by  gas,  and  the  injection  of  water,  the 
patient  being  inverted  during  both  of  these  treatments.  /  do 
not  think  they  should  he  used  under  any  conditions. 

The  injection  of  air  can  be  accomplished  through  a  large 
catheter  or  rectal  tube  by  a  bicycle  or  automobile  tire  pump, 
great  care  and  gentleness  being  exercised.     If  water  is  used  it 


306  THE  DISEASES  OF   CHILDREN. 

can  be  injected  through  the  same  catheter  or  tube,  the  fountain 
syringe  being  held  4  or  5  feet  above  the  patient,  and  3  or  4 
quarts  of  water  used  at  an  injection.  The  hand  should  be  held 
upon  the  tumor  during  this  treatment  so  that  the  reduction  of 
the  intussusception  can  be  ascertained. 

If  reduction  is  perchance  accomplished,  the  child  must  not 
be  fed  for  8  or  10  hours,  kept  in  partly-inverted  position,  and 
under  the  influence  of  an  opiate  for  at  least  two  days. 


CHAPTER  XV. 

GENERAL  DISEASES. 

TYPHOID  FEVER. 

Synonym. — Enteric  fever. 

Definition. — An  acute,  infectious,  febrile  disease  due  to  the 
entrance  into  the  body  of  the  bacillus  of  Eberth. 

Etiology. — The,  disease  is  due  to  the  bacillus  of  Eberth,  which 
is  taken  in  the  body  through  the  stomach,  in  food  or  drink, 
usually  either  water  or  milk.  Infected  dishes  or  spoons  may  con- 
vey the  bacillus,  or  the  hands  contaminated  by  the  discharges 
from  the  bowel  or  kidneys  of  a  patient  with  typhoid  may  carry 
them  to  the  mouth. 

In  638  epidemics  of.  typhoid  fever  17  per  cent  were  due  to 
contaminated  milk,  as  reported  in  "Milk  in  Its  Relation  to  Pub- 
lic Health."  This  reports  138  epidemics  traceable  to  a  specific 
pollution  of  the  milk. 

The  number  of  cases  of  typhoid  fever  occurring  in  the  camps 
during  the  Spanish-American  War  called  attention  to  the  fly 
as  a  disseminator  of  the  contagion  in  a  very  practical  and  serious 
manner.  Levy  believes  the  bacilli  can  enter  the  body  through 
dust.  The  "  typhoid  carrier,"  an  individual  who  apparently 
well;  harbors  virulent  typhoid  bacilli,  may  cause  many  cases. 

Age. — The  infrequency  of  typhoid  in  infancy  is  due  to  the 
number  of  breast-fed  infants;  when  put  on  artificial  food  the 
chance  of  contagion  is  greater.  I  have  seen  one  case  of  typhoid 
develop  in  a  breast-fed  infant  six  months  old,  who  was  weaned 
because  of  typhoid  in  the  mother;  the  attack  in  the  infant  be- 
ginning in  the  third  week  of  the  mother 's  illness. 

Dividing  the  first  15  years  into  equal  parts  the  far  greater 
number  of  cases  of  typhoid  occur  during  the  last  period,  the 
least  during  the  first,  though  it  is  not  infrequent  after  the 
second  year. 

In  this  section  of  the  country,  and  along  the  valleys,  it  occurs 

307 


308  THE  DISEASES   OF    CHILDREN, 

more  frequently  during  the  late  summer  and  fall  months.  A 
prevalence  of  typhoid  is  always  expected  following  the  first  rains 
after  a  prolonged  drouth  where  the  water  supply  is  not  filtered 
or  boiled. 

Bacteriology. — Eberth  first  described  the  bacillus  of  typhoid 
fever  in  1880.  It  is  a  small,  short  organism  with  rounded  ends 
and  very  motile,  with  numerous  flagelli,  the  latter  being  stained 
by  Loeffler's  method.  It  is  both  saprophytic  and  parasitic.  They 
grow  at  room  temperature,  and  are  killed  at  60°  C.  They  are 
very  hardy,  cold  does  not  affect  them,  and  they  live  from  7  to 
10  weeks  on  articles  of  clothing  or  other  objects.  They  grow 
readily  and  characteristically  upon  acid  potato,  bouillon  and 
milk. 

They  are  thrown  off  from  the  body  in  the  discharge  from 
the  bowel  and  kidneys,  both  of  which  may  cause  a  dissemina- 
tion of  the  disease. 

Pathology. — The  bacilli  gain  entrance  to  the  body  through  the 
mouth,  and  because  of  their  resistant  nature  are  not  harmed 
by  the  acid  juices  of  the  stomach,  passing  into  the  intestine,  and 
find  lodgement  in  the  agminated  glands  or  Pyer's  patches.  The 
bacilli  propagate  in  these  glands,  and  as  a  result  there  is  an 
increase  in  the  number  of  cells,  the  gland  undergoing  a  regular 
pathologic  change,  swelling,  necrosis,  ulceration  and  cicatriza- 
tion. From  the  Pyer's  patches  the  bacilli  enter  the  lymphatic 
and  general  blood  circulation,  and  are  found  early  in  the  disease 
in  the  mesenteric  glands,  spleen  and  blood  current,  the  kidneys 
and  skin. 

Autopsy  findings  in  the  very  young  differ  some  from  those 
in  older  children,  in  that  the  ulceration  is  not  so  great  in  in- 
fancy.    The  process  in  older  children  is  similar  to  that  in  adults. 

There  is  decided  enlargement  and  some  softening  of  the  mes- 
enteric lymph  glands,  and  an  enlargement  of  the  spleen.  The 
spleen  can  practically  always  be  palpated  in  typhoid,  as  it  is 
quite  perceptibly  softened  and  enlarged.  The  kidneys  usually 
show  cloudy  swelling. 

Symptoms. — My  experience  has  been  to  find  that,  as  a  rule, 
typhoid  fever  in  children  is  milder,  of  shorter  duration  and 
fewer  complications  than  in  adults. 


GENERAL   DISEASES.  309 

Period  of  Incubation. — The  onset  is  usually  gradual,  though 
it  is  not  at  all  infrequent  for  the  attack  to  be  explosive  in  its 
onset,  with  vomiting  and  fever,  the  child  being  apparently  en- 
tirely well  previously.  During  the  period  of  incubation  it  is 
apt  to  be  droopy,  not  inclined  to  play  or  be  amused;  if  old 
enough  complains  of  headache  and  loss  of  appetite.  There  may 
be  a  slight  rise  of  temperature  at  this  time,  but  it  is  usually 
not  taken  until  the  child  is  believed  to  be  sick.  Not  infre- 
quently there  seems  to  be  an  overwhelming  of  the  nervous  sys- 
tem by  the  toxins,  the  symptoms  at  first  resembling  meningitis. 

Period  of  Fever. — The  typical  fever  curve  of  the  adult  type  of 
typhoid  is  not  always  seen  in  children,  especially  those  cases 
of  the  explosive  type  or  which  begin  with  a  chill.  In  these  the 
temperature  is  high  from  the  onset.  The  temperature  may  be 
found  to  rise  gradually,  with  morning  remissions  and  evening 
rise,  each  day,  both  the  morning  and  evening  record,  being 
higher  than  the  previous  day,  until  the  second  week,  when  the 
temperature  rises  to  about  the  same  line  each  afternoon,  with 
a  degree  or  two  morning  remission.  The  maximum  evening 
temperature  is  usually  not  much  over  104°  F.,  though  it  may  go 
higher. 

During  the  third  week  there  is  a  gradual  fall,  the  morning 
temperature  not  infrequently  reaching  normal  by  the  eighteenth 
day.  The  division  of  these  fever  periods  into  weeks  is  an  en- 
tirely arbitrary  one,  representing  more  the  stages,  the  rise,  the 
continuously  high  fever,  and  the  drop  by  lysis,  than  division 
into  the  seven  days  constituting  a  week. 

Hyperpyrexia  is  infrequent.  A  sudden  drop  in  the  tempera- 
ture to  normal  or  below  is  alarming,  pointing  usually  to  a  hemor- 
rhage from  a  Pyer's  patch. 

The  pulse  increases  in  frequency  as  the  fever  rises,  but  is  usu- 
ally faster  than  would  be  expected.  As  the  temperature  falls 
during  the  third  week,  the  pulse  is  apt  to  be  dicrotic. 

The  tongue  does  not  show  as  marked  change  as  in  the  adult. 
It  is  coated  from  the  beginning  but  rarely  is  as  dry  as  in  adult 
typhoid.  The  coat  becomes  more  marked  in  the  center  and  the 
edges  red.     The  mouth  is  dry  and  often  ulcerated. 

The  stomach  in  the  beginning  may  be  upset.     Early  vomiting 


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GENERAL   DISEASES.  311 

is  not  infrequent,  but  later  is  exceptional.  The  howels  are  dis- 
tended after  the  first  week.  Tympanites  is  not  marked  until  the 
second  or  third  week.  .There  may  be  diarrhea,  but  constipation 
is  very  often  present.  If  diarrhea  is  present  "pea-soup"  dis- 
charges are  the  rule.  It  is  very  frequent  that  enemas  must  be 
given  regularly  to  obtain  evacuations.  Nosebleed  occurs  less 
frequently  in  children. 

The  eruption  of  the  rose-colored  spots  appears  early  in  the 
second  week,  and  is  seen  in  practically  all  cases.  They  are  gen- 
erally on  the  skin  of  the  abdomen,  though  they  may  be  found 
on  any  part  of  the  body.  These  spots  are  small,  papular,  slightly 
raised  and  disappear  on  pressure.  I  have  never  failed  to  find 
them  when  they  were  looked  for  carefully. 

Headache  is  not  a  prominent  symptom  after  the  first  week, 
though  restlessness  may  be  a  feature  after  this  time.  The  head- 
ache at  first  is  often  very  severe  and  suggestive  of  meningitis. 
Stupor  and  delirium  are  frequently  seen  in  children,  the  latter 
being  of  the  low,  muttering  type,  with  picking  at  the  bed 
clothes  or  imaginary  objects  frequent. 

There  is  a  reduction  in  the  number  of  both  the  red  and  white 
hlood  cells,  the  reduction  being  much  greater  after  a  hemor- 
rhage. There  is  a  coincident  decrease  in  the  hemoglobin.  The 
^Yidal  reaction  is  present  early  in  the  second  week.  This  is  a 
typical  reaction  and  is  due  to  the  production  of  a  substance  in 
the  blood,  which  when  added  to  a  solution  containing  active 
typhoid  bacilli  causes  them  to  cease  moving  and  to  form  in 
clumps.  The  urine  is  diminished  in  quantity,  and  during  the 
height  of  the  fever  high-colored  and  of  high  specific  gravity.  The 
toxicity  of  the  urine  is  increased.  "When  the  kidneys  are  in- 
vaded by  the  bacilli,  an  inflammatory  process  is  set  up,  mani- 
fested by  albumin,  hyaline  and  granular  casts.  This  is  a  com- 
plication and  not  seen  in  every  ease. 

The  diazo  reaction  is  present  in  a  large  percentage  of  cases, 
and  somewhat  earlier  than  the  Widal  test — probably  as  early 
as  the  last  of  the  first  week. 

In  inflammatory  conditions  of  the  kidney  due  to  the  presence 
of  the  bacilli,  the  organisms  can  be  found  in  the  urine. 

The  lymph  nodes  are  enlarged  and  can  be  palpated  in  the 


312 


THE  DISEASES  OP   CHILDREN. 


neck,  axilla  and  groin,  though  they  do  not  reach  the  size  of 
the  nodes  in  the  other  infectious  diseases.  The  spleen  is  palpa- 
ble throughout  most  of  the  attack. 

Complications. — Hemorrhage  is  seen  less  often  in  children 
than  adults.  It  occurs  usually  at  the  end  of  the  second  or  begin- 
ning of  the  third  week.     I  have  observed  hemorrhages  but  twice 


Fig.   60. — Typhoid  fever ;  hemorrhage ;  perforation. 

in  children.  A  hemorrhage  is  very  regularly  followed  by  a  drop 
in  the  temperature  of  from  3°  to  5°  F.,  a  corresponding  increase 
in  the  pulse  rate  and  acute  anemia  and  prostration. 

Perforation  occurs  more  often  in  the  hemorrhagic  cases.  Its 
occurrence  is  associated  with  sudden  and  acute  pain,  and  prob- 
ably some  rigidity  of  the  abdomen,  but  there  are  no  other  de- 
cided symptoms  which  are  always  present.  Peritonitis  follows 
a  perforation  in  a  short  time,  shock  is  usually  ])i'esent,  and  a 
fatal  termination  prompt.  In  the  only  case  which  has  come 
under  my  observation  the  following  history  presented : 

Boy,  aged  13,  irregular  temperature  for  one  week,  continuously  between 
101°   and  103°  F.  after  the  sixth  day;    first  spots  noted  on  the  twelfth 


GENERAL   DISEASES.  313 

and  thirteenth  days.  Active  delirium  from  the  seventeenth  day,  with  great 
restlessness;  nosebleed  on  twenty-second  day,  with  hemorrhage  from  the 
bowel  on  the  twenty-third  day,  and  a  very  large  intestinal  hemorrhage  on 
the  twenty-fourth  day.  Temperature  chart  from  the  twenty-third  day  until 
death  is  given.  Twenty-sixth  day  the  pulse  was  130  and  very  weak;  twenty- 
seventh,  vomits  nourishment;  thirtieth  day,  rational  at  times  and  com- 
plains constantly  of  pain  in  his  abdomen;  thirty-first  day  completely  deaf; 
death  on  the  thirty-second  day  of  his  illness.  Postmortem  showed  general 
peritonitis,  fluid  in  pelvis,  bowel  covered  with  thick  layers  of  plastic  lymph; 
one  perforation,  punched  out  in  appearance,  one-fourth  inch  in  diameter, 
about  10  inches  from  the  cecum;  no  adhesions  about  perforation. 

Bronchitis  is  a  frequent  complication  and  a  bronchopneu- 
monia not  uncommon.  The  occurrence  of  a  rapid  respiration, 
slightly  higher  temperature  and  cough  is  sufficient  to  cause  the 
respiratory  organs  to  be  suspected.  The  bronchopneumonia  is 
hypostatic  in  character  and  occurs  as  a  late  complication,  while 
bronchitis  is  seen  earlier. 

Chorea  may  develop  late  in  the  attack  or  during  convalescence. 
Reports  of  melancholia  and  mania  have  been  made  as  complica- 
tions of  typhoid  fever. 

Otitis  media,  due  to  the  direct  infection  of  the  middle  ear 
by  the  bacillus,  occurs  in  a  small  percentage  of  cases.  It  is 
usually  mild,  and  tends  to  recovery  without  complications. 

Aphasia  is  an  infrequent  complication,  but  a  very  striking 
one.     The  following  case  is  illustrative: 

Lucile  M.,  aged  five  and  a  half  years,  the  only  child  of  a  young  mother. 
She  was  spoiled  and  petted,  and  was  taken  rather  suddenly  ill  the  first 
week  in  January,  1906.  Typhoid  fever  was  early  suspected  by  the  attend- 
ing physician,  but  the  diagnosis  was  not  confirmed  until  January  8,  when 
the  rose  spots  were  first  discovered.  It  was  entirely  impossible  for  the 
child  to  be  controlled  at  the  home  of  her  parents,  and  she  was  removed 
to  the  residence  of  a  relative  of  whom  she  was  very  fond.  Every  member 
of  the  family  was  ostracised,  and  the  cliild  put  in  the  entire  charge  of  a 
day  and  a  night  nurse. 

It  is  difficult  to  adequately  convoy  the  imj)rcssion  of  the  kind  of  patient 
we  had  to  deal  witli  in  this  little  girl.  She  was  wilful,  peevish,  ])etulant, 
iross,  doliant  and  extreniidy  diiricult  to  control.  From  the  temperature 
chart  exhibited  it  can  be  seen  that  the  course  of  her  attack  was  moderately 
severe.  The  maximum  temperature  was  105°  F.,  reached  on  the  thirteenth 
and  fourteentli  of  January,  the  seventh  and  eighth  days  of  her  attack.  The 
impression  of  the  toxins  on  the  central  nervous  system  was  quite  profound, 


314  THE   DISEASES  OP   CHILDREN". 

there  being  delirium,  involuntary  passages  from  both  bowel  and  bladder, 
and  muttering  talk.  On .  the  seventeenth  day  there  was  difficulty  in  swal- 
lowing, but  this  was  of  only  two  or  three  days'  duration. 

Three  or  four  days  after  the  temperature  reached  normal  the  child  was 
noticed  to  mumble  its  words,  where  her  speech  previously  had  been  all 
right.  She  did  not  articulate  plainly  enough  to  be  understood.  She  was 
asked  if  she  wanted  a  drink  of  water  and  seemed  frightened  when  she  could 
not  reply.  From  this  time  for  three  weeks  she  did  not  utter  a  sound.  At 
the  end  of  this  time  she  was  heard  to  make  a  sound;  in  a  few  minutes 
she  mumbled  unintelligible  words,  much  as  she  had  done  at  the  beginning 
of  the  attack.  For  two  or  three  days  this  mumbling  continued  and  by 
the  end  of  the  week  she  was  talking  plainly.  She  did  not  have  to  be  taught 
words  or  their  meaning.  As  soon  as  she  began  to  articulate  she  had  no 
difficulty  in  the  least  in  framing  sentences. 

Her  convalescence  from  this  time  was  uneventful  and  rapid.  During 
the  next  winter  she  attended  school  for  the  first  time,  however,  being  kept 
out  of  her  class  on  account  of  whooping  cough  and  measles  for  a  good  por- 
tion of  the  time,  yet  she  was  promoted  to  the  next  grade. 

Furunculosis  is  often  observed  in  children.  Inflammatory 
joi7it  lesions  occur  during  the  latter  part  of  the  disease  or  during 
convalescence,  and  occasionally  bony  changes,  abscess  of  the 
bones  being  the  most  frequent  form  of  trouble. 

Diagnosis. — Diagnosis  must  be  made  chiefly  from  tubercu- 
losis, malaria,  gastrointestinal  infection,  pyelitis,  meningitis,  sep- 
sis, appendicitis.  Among  the  chief  diagnostic  points  may  be 
mentioned  the  fairly  typical  temperature,  enlarged  spleen, 
rose-colored  spots  and  the  laboratory  methods  of  diagnosis; 
Ehrlieh's  diazo  reaction  and  the  Widal  test.  The  diazo  reaction 
is  obtained  as  follows:  Two  solutions  are  prepared,  (1)  a  satu- 
rated solution  of  sulphanilic  acid  in  1000  cc.  of  water  and  50  ec. 
hydrochloric  acid;  (2)  a  0.5  per  cent  solution  of  sodium  nitrite. 
To  10  cc.  of  the  sulphanilic  acid  solution  in  a  test  tube  are 
added  4  drops  of  the  sodium  nitrite  solution  and  10  cc.  of  the 
suspected  urine.  These  are  well  shaken,  and  a  layer  of  am- 
monia floated  on  the  surface.  A  bright-red  ring  at  the  point  of 
contact  of  the  two  solutions  appears  if  the  urine  is  from  a  typhoid 
case.  A  deep-red  color  should  also  appear  in  the  fluid  and  the 
foam  when  the  solution  is  well  shaken. 

The  Widal  test  ^  is  made  as  follows : 

A  drop  of  fresh  or  dried  blood  from  the  ear  of  the  patient  is 

*  French :   Practice  of  Medicine. 


GENERAL   DISEASES.  315 

diluted  with  5,  10  and  25  or  more  times  as  much  saline  solution. 
A  drop  of  fresh,  virulent  bouillon  culture  of  typhoid  bacilli  is 
then  added  to  each,  thus  forming  dilutions  of  1 :10,  1 :20  and 
1 :50,  respectively.  The  specimens  are  immediately  exam- 
ined under  the  microscope  in  the  hanging  drop.  The  typhoid 
culture  should  be  from  18  to  24  hours  old  and  made  from  a 
stock  culture  that  is  known  to  react  readily  to  the  serum  test. 
It  should  be  examined  in  the  hanging  drop  before  the  serum 
has  been  added  in  order  to  see  that  it  is  free  from  clumping. 
If  the  bacilli  are  very  numerous,  the  culture  may  be  diluted 
with  salt  solution.  The  agglutination  may  occur  immediately 
or  after  10  or  15  minutes.  The  bacilli  appear  grouped  together 
in  irregular  tufts  of  variable  size  and  become  motionless.  The 
time  at  which  the  reaction  becomes  distinct  in  the  different  dilu- 
tions should  be  recorded.  In  the  dilution  of  1 :10  an  imme- 
diate agglutination  generally  takes  place.  It  may  occur  in  a 
dilution  of  1 :50,  1 :100,  or  even  higher.  A  specially  devised 
agglutinometer  for  making  the  test  without  the  use  of  living 
cultures  or  the  microscope  may  be  employed. 

The  absence  of  this  reaction  throughout  a  disease  may  be 
regarded  as  positive  evidence  that  typhoid  fever  is  not  present, 
since  it  has  been  found  in  97.9  per  cent  of  4897  cases  collected 
by  Brill. 

An  agglutination  of  the  typhoid  bacillus  has  been  obtained 
from  the  blood  of  patients  suffering  with  malaria,  typhus,  mil- 
iary tuberculosis,  cerebrospinal  meningitis,  and  other  acute  in- 
fections, but  rarely  in  a  higher  dilution  than  1 :5.  A  reaction 
obtained  from  a  dilution  of  1 :30  is,  therefore,  a  positive  demon- 
stration of  typhoid  fever  in  nearly  all  cases,  unless  the  patient 
has  previously  passed  through  the  disease,  for  the  blood  often 
continues  to  agglutinate  the  bacilli  for  many  years  after  re- 
covery. About  half  the  cases  do  not  give  a  positive  reaction 
before  the  beginning  of  the  second  week,  and  about  a  third  of 
the  cases  do  not  give  a  reaction  before  the  early  part  of  the 
third  week.  It  may  appear,  on  the  other  hand,  as  early  as  the 
fourth  or  fifth  day.     Rarely,  it  is  first  obtained  in  a  relapse. 

Tuberculosis.  There  may  be  some  difficulty  in  differentiating 
this  disease  from  typhoid,  and  the  laboratory  aids  to  diagnosis 


316  THE   DISEASES   OF   CHILDREN. 

may  have  to  be  called  upon  to  clear  it  up.  The  occurrence  of  a 
previous  pneumonia,  pertussis,  prolonged  bronchitis,  emacia- 
tion, etc.,  is  more  common  in  tuberculosis.  In  tubercular  men- 
ingitis the  mental  symptoms  are  prominent  early  and  become 
gradually  more  profound,  while  in  typhoid  the  meningeal  symp- 
toms appear  early. 

Malaria  in  the  South  may  be  mistaken  for  typhoid.  The 
presence  of  the  Plasmodium  in  the  blood  and  the  response  of  the 
condition  to  quinine  are  diagnostic  points  of  value. 

Gastrointestinal  infection  may  present  symptoms  which  are 
confusing.  Usually  the  temperature  curve  is  not  so  high  or  long 
and  the  intestinal  symptoms  are  riiore  marked. 

Pyelitis  is  very  apt  to  be  confused.  In  one  of  my  cases  of 
pyelitis,  because  of  the  inability  to  obtain  a  sample  of  urine  for 
some  days,  typhoid  was  strongly  suspected,  but  the  diagnosis 
was  cleared  up  as  soon  as  a  microscopic  examination  was  made 
of  the  urine. 

Septic  conditions,  such  as  arise  in  Pott's  disease  of  the  spine 
with  abscess  formation,  abscess  of  the  liver,  and  other  deep- 
seated  abscesses  may  be  confusing  at  first. 

Close  observation  and  inspection  of  the  abdomen  should  make 
the  differentiation  between  appendicitis  and  typhoid  easy.  The 
rigidity  of  the  abdomen  and  tumor  with  abscess  formation  is 
quite  typical  of  appendicitis. 

Prognosis. — In  uncomplicated  cases  the  prognosis  is  good. 
The  younger  the  child  the  more  grave  the  prognosis.  Hemor- 
rhagic cases  are  more  often  fatal.  Griffiths  reports  a  mortality 
of  3  per  cent,  Abt  reports  a  mortality  of  2.9  per  cent.  Perfora- 
tion is  always  fatal  without  operation.  The  course  is  milder 
in  children  and  the  duration  shorter  as  a  rule. 

Treatment.  Prophylaxis. — Proper  care  and  disinfection  of 
the  evacuations  and  urine  of  typhoid  fever  patients  would 
greatly  lessen  the  number  of  cases  which  are  annually  seen.  In 
the  country,  wells  and  cisterns  should  be  carefully  protected 
from  sewerage  and  drainage  from  the  house,  and  removed  from 
the  outhouses  and  privies.  In  cities,  unless  the  city  water  supply 
is  filtered,  all  water  which  is  given  the  children  should  be  care- 
fully boiled.     Only  a  certified  milk  should  be  used  where  it  is 


GENERAL   DISEASES.  317 

obtainable.  If  a  market  milk  is  used  the  dairy  from  which"  it 
comes  should  be  visited  and  the  methods  of  the  dairyman 
learned.  Frequent  inquiry  should  be  made  as  to  the  presence 
of  illness  on  this  place,  and  if  these  conditions  are  unsatisfac- 
tory the  milk  should  be  Pasteurized  or  sterilized  before  being 
used. 

If  a  ease  of  typhoid  occurs  in  a  private  family  careful  and 
explicit  directions  must  be  given  to  other  members  of  the  family. 
Crude  carbolic  acid  should  be  added  to  the  feces  before  it  is 
emptied,  and  all  vessels  and  utensils  used  by  the  patient  should 
be  used  by  him  exclusively  and  boiled  each  day. 

A  tub  containing  a  1 :3000  bichloride  of  mercury  solution  or 
a  1:20  carbolic  acid  solution  should  be  provided,  in  which  the 
bed  linen  is  soaked  before  it  is  washed.  It  should  not  be  washed 
with  the  other  household  linen.  Squares  of  soft  cloth  or  gauze 
should  be  used  instead  of  handkerchiefs,  and  these  burned  when 
soiled. 

Management. — The  presence  of  fever  from  any  cause  in  a 
child  is  an  indication  for  it  to  be  kept  in  bed,  but  especially  so 
when  typhoid  fever  is  suspected.  The  best  room  in  the  house 
should  be  chosen,  with  bath  room  and  toilet  conveniences  nearby. 
No  matter  how  young  the  child  it  can  be  kept  in  bed,  and  if  it 
is  put  in  charge  of  a  nurse  who  is  gentle,  yet  firm,  this  can 
be  accomplished.  It  is  rare  that  the  youngest  patient  has  to  be 
taken  up  and  held.  Its  position  should  be  frequently  changed, 
not  allowing  it  to  lie  long  in  any  position.  It  should  not  be 
allowed  to  get  up  to  the  vessel,  but  should  be  taught  to  use  the 
bed  pan.  No  company  should  be  allowed,  no  one  in  the  room 
but  the  nurse  and  mother. 

A  bedside  record  is  an  essential  in  the  conduct  of  a  typhoid, 
and  a  temperature  chart  or  tracing  just  as  important.  In  no 
other  way  can  the  run  of  the  fever  of  a  typhoid  be  so  accurately 
kept  track  of  as  by  the  use  of  the  temperature  chart.  Tempera- 
ture, pulse  and  respiration  should  be  taken  every  four  hours. 

The  child's  eyes  should  be  protected  from  the  direct  light, 
but  the  room  should  be  bright  and  airy,  the  temperature  not 
more  than  65°  or  70°  F.  The  bed  should  be  comfortable,  pushed 
away  from  the  wall  so  as  to  be  approached  from  all  sides,  with 


318  THE   DISEASES   OF    CHILDREN. 

a  firm,  but  not  too  hard  mattress.  The  mattress  should  be  pro- 
tected by  a  rubber  sheet,  but  plenty  of  thicknesses  of  sheets  or 
pads  to  protect  the  skin,  otherwise  a  sudamina  or  heat  rash  will 
be  caused  from  the  rubber  sheet.  The  gown  and  sheet  should 
be  kept  free  from  wrinkles  at  all  times. 

A  daily  general  soap  and  water  cleansing  bath  should  be 
given,  as  nothing  so  adds  to  the  comfort  of  the  child.  This 
should  be  given  irrespective  of  the  baths  given  for  temperature. 
The  judicious  application  of  a  50  per  cent  solution  of  alcohol 
to  the  hips  and  back  will  prevent  bed  sores  developing. 

The  mouth  and  teeth  should  be  carefully  watched  and  washed 
at  frequent  intervals.  A  very  pleasant  mouth  wash  is  the 
following : 

R  Glycerine  3^^^ 

Listerine  3^^ 

Lemon  juice  3ss 

M.  ft.  Mouth  wash. 

The  mouth  should  be  rinsed  after  every  feeding  and  the  mouth 
wash  used  in  the  interval. 

Diet. — No  other  phase  of  the  management  of  typhoid  is  so 
important  and  so  difficult  to  control  as  the  feeding  of  the  pa- 
tient. Milk  as  an  exclusive  diet  in  typhoid  is  not  well  borne. 
It  offers  an  excellent  culture  medium  for  the  organisms  which 
are  found  in  the  intestine  with  the  typhoid  bacillus.  The  same 
objection  obtains  in  the  exclusive  use  of  the  animal  broths  also, 
as  they  do  not  meet  the  demands  of  the  nutrition.  If  milk  is 
well  borne  it  should  be  well  diluted,  with  a  low  fat  percentage. 
Frequently  a  fat-free  buttermilk  is  well  borne  and  relished.  It 
may  be  necessary  to  peptonize  the  milk  if  there  are  evidences 
that  the  proteids  are  causing  an  irritation.  If  a  diarrhea  begins, 
the  milk  should  be  withdrawn.  Dr.  F.  W.  Werner  of  Joliet, 
111.,  recommends  strongly  the  exclusive  use  of  hot,  weak  tea, 
claiming  for  the  tea  that  it  is  bacterir-idal,  and  the  ihui]  and 
slightly  stimulating  effect  of  the  tea  are  beneficial. 

Food  should  be  liquid  and  given  at  regular  intervals,  and  in 
less  quantity  than  in  health.  Three  to  four  ounces  every  four 
hours  during  the  day  and  twice  during  the  night  is  ample,  with 
a  liberal  amount  of  water  between. 


GENERAL   DISEASES.  319 

Cereal  decoctions,  dextrinized,  are  well  borne,  and  usually 
taken  with  a  relish.  They  can  be  flavored  with  the  broths,  beef 
juice  or  with  sherry,  if  not  otherwise  well  taken. 

The  caloric  method  of  feeding  in  typhoid  is  attracting  much 
attention,  emphasis  being  laid  on  the  carbohydrates  to  increase 
the  nutritive  value  of  the  food. 

Stimulation. — Stimulants  should  never  be  given  as  routine, 
but  reserved  until  they  are  absolutely  indicated,  as  they  fre- 
quently are  late  in  the  attack.  When  the  heart  beat  is  weak 
and  flagging  or  dicrotic,  alcohol  is  of  decided  benefit,  especially 
when  the  second  sound  of  the  heart  is  muffled  or  weak.  Only 
the  best  bottled-in-bond  article  of  whisky  or  equally  good  brandy 
should  be  selected.  Children  stand  whisky  well  and  respond  to 
its  effects  quickly.  A  half  to  one  teaspoonful  well  diluted  can 
be  given  to  a  child  of  one  year  for  its  effect,  every  three  or  four 
hours.  Digitalis  (2  to  5  min.),  strophanthus  (2  min.),  both  in 
the  form  of  the  tincture;  sulphate  of  strychnine  (1/200  gr.)  by 
the  mouth  or  hypodermically  to  a  child  of  two  years,  or  nitro- 
glycerine (1/500  gr.)  in  emergencies. 

Fever. — ^A  temperature  below  103°  F.  does  not  need  any 
special  treatment,  but  when  it  rises  to  103°  F.  or  over  it  should 
be  reduced.  Coal-tar  antipyretics  should  never  be  given,  and 
resort  must  be  had  to  hydrotherapy,  which  can  be  administered 
by  the  sponge,  tub  or  pack.  If  the  child  is  under  two  years  of 
age  it  can  be  put  in  the  tub  without  trouble,  but  a  tub  bath  is 
difficult  to  give  to  older  children  without  extra  assistance.  Low- 
ering the  child  into  the  water  on  a  sheet  stretched  across  the 
tub  wall  often  be  of  great  assistance.  The  water  should  be 
warm,  85°  or  90°  F.,  and  cooled  from  5°  to  8°  by  adding  cool 
water  at  the  foot  of  the  tub  and  thoroughly  mixing.  The  bath 
is  prolonged  for  10  minutes,  or  a  shorter  time  if  there  is 
shock  or  much  nervousness  and  crying.  The  constant  gentle 
friction  of  the  legs,  arms  and  body,  avoiding  the  abdomen,  will 
make  the  bath  much  more  efficient,  and  a  drop  of  2°  or  3° 
generally  results.  The  application  during  the  bath  of  a  cold, 
wet  compress  to  the  child's  head  is  of  assistance. 

The  sponge  bath  is  often  equally  as  efficient  as  the  tub  bath. 
The  child  is  placed  between  blankets,  and  first  one  member  and 


320  THE   DISEASES   OF    CHILDREN. 

then  another  is  exposed  and  bathed  with  a  piece  of  gauze  thor- 
oughly wet,  but  not  dripping,  in  water  of  85°  or  90°  F.,  with 
long,  slow  strokes;  then  the  back,  first  gently  turning  patient  on 
the  side,  and  lastly  the  abdomen  and  chest.  The  whole  process 
should  occupy  from  20  to  30  minutes.  The  pack  applied  ac- 
cording to  Kerley  is  very  efficient.  The  jacket  or  pack,  long 
enough  to  reach  below  the  knees,  with  arm  holes,  is  put  on  the 
child  dry,  and  with  a  large  sponge  the  water,  at  90°  F.,  is 
mopped  on  the  pack  until  it  is  thoroughly  wet.  As  the  pack 
dries,  fresh  water  is  applied,  gradually  cooler,  and  the  pack 
continued  until  the  temperature  is  reduced.  The  temperature 
of  the  child  should  be  taken  at  least  half  an  hour  after  the  bath 
and  finding  recorded.  The  drop,  as  shown  on  -the  temperature 
chart,  should  be  indicated  by  an  8,  indicating  a  sponge,  or  B. 
for  bath. 

Bowels. — ^As  a  rule  constipation  is  present  during  typhoid, 
and  much  more  to  be  desired  than  diarrhea.  The  place  which 
intestinal  antiseptics  occupy  in  the  treatment  of  typhoid  fever 
is  a  moot  one.  Personally  I  never  employ  them,  and  my  results 
have  been  as  good  as  my  confreres  who  use  them.  Enemata  of 
saline  solution  is  usually  all  that  is  needed  to  obtain  an  action 
from  the  bowels,  and  they  should  be  given  regularly.  An  occa- 
sional dose  of  castor  oil  is  of  great  benefit  or  small  dose  of  cas- 
cara,  20  or  30  drops,  of  any  of  the  aromatic  preparations. 

What  constitutes  a  diarrhea  is  a  matter  of  individual  opinion. 
More  than  three  movements,  if  thin,  should  be  considered  ab- 
normal and  call  for  treatment.  If  thin  and  containing  undi- 
gested food,  a  preliminary  dose  of  castor  oil  should  be  given, 
followed,  when  it  has  acted,  with  bismuth  subnitrate  (gr.  x  or 
gr.  XV  every  three  hours).  Morphia  is  rarely  indicated,  but 
may  be  needed  in  very  small  doses. 

Tympanites. — For  the  dry  tongue  and  tympanites  of  the  third 
week,  no  drug  can  take  the  place  of  turpentine,  both  internally 
and  locally.  It  is  difficult  to  give  internally  to  a  child,  either 
in  an  emulsion  or  otherwise,  but  can  be  used  as  a  stupe  as  fol- 
lows: 

IJ  01.  terebinthinae  3i 

01.  olivse  p. 


GENERAL   DISEASES.  321 

M.  Sig.  Kub  one  teaspoonful  over  the  entire  abdomen,  and  place  over 
this  the  hot  wet  flannel,  which  should  be  renewed  at  half-hour  intervals. 

The  stupes  should  be  watched  closely  as  there  is  danger  of 
producing  strangury  if  they  are  kept  up  too  long  at  a  time. 

Internally,  turpentine  can  be  given  in  3  to  5  drop  doses  in  an 
emulsion  flavored  with  peppermint. 

Hemorrhage. — This  is  the  most  alarming  of  any  complication 
which  may  arise.  If  the  blood  passed  is  black  and  no  perceptible 
impression  has  been  made  upon  the  pulse,  no  special  active  treat- 
ment except  starvation  is  required,  but  if  the  blood  is  bright, 
and  there  is  a  coincident  fall  in  the  temperature  and  rise  in 
pulse  rate,  active  measures  are  indicated  at  once.  The  foot  of 
the  bed  is  raised,  an  ice  bag  or  coil  is  applied  to  the  abdomen, 
morphine  is  given  hypodermically  (gr.  1/60),  and  all  food  and 
water  is  withheld  in  order  to  stop  the  peristalsis.  Gelatin  by 
the  mouth  and  subcutaneously  is  of  benefit  in  profuse  hemor- 
rhages, and  if  doubly  sterilized,  risk  from  infection  from  hypo- 
dermic use  is  lessened.  Hypodermatic  injection  of  normal  horse 
serum  should  be  tried,  also.  Feeding  is  resumed  very  tenta- 
tively. 

Convalescence. — This  is  a  most  important  period,  especially 
as  to  diet,  and  the  patient  must  be  constantly  curbed  and  watched 
in  order  to  prevent  overdoing  and  a  possible  reinfection  or  re- 
lapse. The  diet  should  continue  the  same  until  the  tempera- 
ture has  been  normal  a  week,  except  more  can  be  given  at  a 
time,  when  the  following  list  can  be  followed  for  a  child  of 
three  years  or  more : 

First  Day.  To  take  the  place  of  one  liquid  feeding,  a  thick 
gruel  of  strained  oatmeal. 

Second  Day.     Rice  and  milk. 

Third  Day.     Boiled  custard. 

Fourth  Day.     ]\Iilk  toast,  crust  cut  off. 

Fifth  Day.     Baked  potato,  thoroughly  mashed. 

Sixth  Day.     Soft-boiled  egg,  one  feeding  rice. 

Seventh  Day.  Scraped  beef,  broiled  lightly.  During  first 
part  of  the  second  week  the  same  articles  can  be  given,  only 
two  in  one  day,  and  during  the  latter  part  more. 


322  THE  DISEASES  OF   CHILDREN. 

RHEUMATISM. 

Synonym. — Rheumatic  Fever. 

Etiology. — The  specific  cause  of  rheumatic  fever  or  rheuma- 
tism has  not  been  located,  but  the  clinical  symptoms  point  to 
some  cause  of  an  acute  infectious  nature,  and  the  finding  of  a 
diplococcus,  practically  identical,  by  both  Triboulet  and  Was- 
sermann,  is  confirmatory  of  this  theory.  That  it  can  be  due  to 
uric  acid  or  lactic  acid  does  not  seem  probable. 

The  association  of  tonsillitis  and  pharyngitis  with  rheuma- 
tism, or  these  conditions  being  a  manifestation  of  rheumatism, 
must  be  borne  in  mind. 

It  is  infrequent  in  infants  under  two  years  of  age;  from  this 
to  five  years  the  course  is  very  unlike  rheumatism  in  the  adult, 
and  may  go  unrecognized.  No  joint  development  may  be  pres- 
ent.    In  older  children  the  history  is  much  the  same  as  in  adults. 

Exposure  and  fatigue  predispose  to  an  attack.  Eelapses  and 
recurrences  are  frequent.     Heredity  must  be  reckoned  with. 

Pathology. — All  of  the  serous  membranes  of  the  joints  and 
of  the  heart  may  be  affected.  There  is  a  congestion  and  swell- 
ing, with  effusion  both  in  the  joint  and  in  the  surrounding  cellu- 
lar tissue.  The  frequency  of  involvement  of  the  endocardium 
in  children  is  much  greater  than  in  adults.  The  pericardium 
is  not  infrequently  involved  also.  The  involvement  of  the  heart 
occurs  often  when  there  are  but  few  joints  involved,  and  they 
but  slightly.  The  changes  in  the  heart  may  precede  the  arthritis. 
The  change  in  the  heart  is  the  result  of  the  action  of  the  infective 
cause  of  the  rheumatism,  either  bacteria  or  their  toxins,  chiefly 
affecting  the  membrane  lining  the  valves.  The  mitral  valve  is 
the  most  frequently  involved.  As  a  result  of  the  action  of  the 
bacteria,  a  hyperplasia  of  the  tissue  takes  place  with  the  forma- 
tion of  vegetations  on  the  valve.  This  prevents  the  free  closure 
of  the  valve,  and  as  a  result  an  obstruction  to  the  flow  of  the 
blood  current  or  a  regurgitation  from  imperfect  closure. 

Symptoms. — These  may  be  so  mild  as  to  pass  unrecognized. 

The  child  may  complain  of  vague  pains  in  the  joints  and  limbs, 
which  are  ordinarily  called  "growing  pains,"  but  which  are  not 
infrequently  associated  with  serious  and  severe  heart  lesions. 
Hence,  any  joint  pain  in  a  child  should  not  be  treated  lightly. 


GENERAL   DISEASES.  323 

In  typical  attacks,  of  the  adult  type,  there  is  a  chill  or  rigor, 
followed  by  an  elevation  of  temperature  from  102°  to  105°  F. 
There  is  languor  and  lassitude,  followed  shortly  by  pain  and 
swelling  of  the  joints.  The  number  of  joints  affected  varies 
greatly,  occasionally  only  one  or  two  of  the  large  joints  are 
involved,  though  all  may  be  swollen  and  tender.  One  of  the 
large  joints,  as  the  knee,  and  several  of  the  smaller  joints  may 
be  involved  at  one  time. 

It  is  in  those  cases  with  insufficient  pain  to  keep  them  in 
bed  that  the  most  serious  involvement  of  the  heart  is  seen.  The 
pulse  may  be  irregular  and  of  less  volume  and  a  physical  ex- 
amination of  the  heart  reveals  the  beginning  heart  lesion. 
Herz's  arm  test  is  a  good  method  of  learning  the  functional  ca- 
pacity of  the  heart.  The  elbow  is  supported  by  the  hand,  and 
with  the  free  hand  the  wrist  of  the  patient  is  grasped  and  the 
child  told  to  make  slow  flexion  of  the  forearm.  The  examiner 
does  not  resist  this  movement.  Extension  is  then  made  as 
slowly,  the  child  concentrating  his  attention  to  these  acts.  The 
pulse  is  then  counted  and  compared  with  the  count  made  imme- 
diately previous  to  the  test.  If  the  myocardium  is  not  abso- 
lutely sound  the  pulse  rate  is  slowed  and  the  size  and  strength  of 
the  pulse  wave  lessened.  One  drop  of  the  tincture  of  digitalis 
can  be  given  a  child  of  seven  years,  and  if  the  myocardium 
is  not  normal  there  will  be  a  difference  in  the  pulse  wave  and 
rate  from  that  previous  to  its  ingestion. 

Duration. — The  acute  symptoms  usually  last  from  a  week  to 
10  days,  though  the  pain  may  continue  some  time  longer. 

Complications. — Tonsillitis  occurs  with  or  may  precede  by  a 
few  days  the  acute  symptoms  of  rheumatism.  In  fact  a  severe 
attack  of  tonsillitis  may  be  the  only  manifestation  of  rheu- 
matism, and  be  followed  by  an  endocarditis,  hence  an  attack  of 
tonsillitis  or  pharyngitis  should  be  regarded  with  suspicion. 

Chorea  is  closely  allied  to  rheumatism,  and  may  occur  during 
the  attack  or  follow  it.  Close  questioning  in  cases  of  chorea 
will  usually  bring  out  a  previous  history  of  rheumatism. 

Siihcutaneous  nodules  occur  in  the  fibrous  or  connective  tissue 
of  the  skin,  from  the  size  of  a  pin  head  to  a  small  pea,  being 
scattered  particularly  over  the  ends  of  the  long  bones  and  the 


324  THE   DISEASES   OF    CHILDREN. 

vertebne.  They  may  not  be  visible  on  superficial  inspection, 
but  are  easily  felt  on  palpation.  They  are  not  painful  or  ten- 
der. No  satisfactory  explanation  has  been  offered  for  their 
appearance.  Heart  changes  have  been  referred  to  on  a  previous 
page. 

Various  shin  lesions  may  appear  during  an  attack  of  rheuma- 
tism. Sudamina  and  miliaria,  the  inflammatory  form  of  sud- 
amina,  may  develop  because  of  the  overactive  sweat  glands 
and  the  acidity  of  the  secretion.  Erythema  nodosum  is  of 
rather  frequent  occurrence.  These  nodes  appear  principally 
upon  the  anterior  surfaces  of  the  tibia,  are  the  size  of  a 
bean,  discolored  usually,  and  are  quite  tender  on  pressure.  They 
may  persist  after  the  subsidence  of  the  acute  pain.  They  occur 
more  frequently  in  females.  Purpura  hemorrhagica  may  be 
present,  with  petechial  spots  or  larger  hemorrhagic  subcutaneous 
areas  here  and  there.  Herpes  and  urticaria  are  uncommon  but 
do  occur.  Peliosis  rheumatica,  Schonlein's  disease,  consists  of 
reddish,  raised  papules,  which  are  purpuric. 

Pulmonary  lesions  are  not  uncommon,  especially  bronchitis 
and   bronchopneumonia.     They   are   probably  of  septic   origin. 

The  anemia,  which  is  always  present  to  a  certain  extent,  may 
become  quite  marked,  and  in  the  convalescence  prove  of  some 
moment  in  the  ultimate  complete  recovery. 

Diagnosis. — This  is  principally  from  scorbutus,  rachitis,  ar- 
thritis, of  septic,  gonorrheal  and  tuberculous  origin,  and  espe- 
cially in  infancy  these  conditions  must  be  ruled  out. 

In  a  large  percentage  of  cases  of  scurvy  the  first  diagnosis 
made  has  been  rheumatism,  and  frequently  not  until  the  soften- 
ing of  the  gums  and  hemorrhages  of  the  subcutaneous  tissue 
and  mucous  membrane,  that  the  diagnosis  of  scurvy  is  made.  In 
scurvy  without  complications  there  is  no  fever,  which  is  a  prom- 
inent symptom  of  acute  rheumatism. 

The  bony  changes  in  rachitis,  no  fever,  head  sweats  and  his- 
tory should  aid  the  diagnosis. 

In  septic  arthritis  and  osteomyelitis  the  general  symptoms  and 
condition  of  the  patient  is  much  more  severe  than  in  rheuma- 
tism, and  the  lesion  more  centered  in  but  one  or  at  the  most  two 
joints  at  a  time. 


GENERAL   DISEASES.  325 

Gonorrheal  arthritis  is  not  frequent  in  children,  but  may 
present  symptoms  so  similar,  that  without  a  history  of  a  vagin- 
itis or  vulvovaginitis,  a  diagnosis  will  not  be  made  until  anti- 
rheumatic agencies  fail  to  relieve  symptoms.  In  scarlatinal  ar- 
thritis the  previous  history  and  the  presence  of  desquamation 
will  clear  up  the  diagnosis. 

Prognosis. — As  far  as  the  risk  to  life  is  concerned  the  prog- 
nosis is  quite  good,  provided  there  is  no  serious  involvement  of 
the  heart.  Recurrences  are  very  frequent.  A  valvular  inflam- 
mation may  be  present  without  permanent  involvement  or  crip- 
pling of  the  valve,  but  owing  to  the  possibility  of  recurrence, 
with  little  or  no  joint  symptoms  and  severe  heart  involvement, 
the  prognosis  should  be  guarded. 

Treatment. — The  first  positive  indication  is  to  put  the  child 
to  bed  and  keep  it  at  rest  until  all  symptoms  have  disappeared. 
The  diet  should  be  largely  liquid  at  first,  with  no  meats  or  ani- 
mal broths.  Plenty  of  water  should  be  insisted  upon.  Milk  or 
any  food  in  which  it  enters  should  be  the  chief  diet.  There  are 
no  objections  to  occasional  feedings  of  the  cereals,  especially  if  a 
diastase  be  given  afterward.  "With  the  subsidence  of  the  fever, 
meat  extracts  or  broths  can  be  given;  finally  scraped  beef,  fowls 
and  vegetables. 

The  bowels  must  be  carefully  regulated,  and  if  possible  one 
of  the  salines  given  each  morning.  Sodium  phosphate  in  half 
or  full  teaspoon  doses,  well  diluted,  is  of  benefit. 

The  affected  joints  are  made  more  comfortable  if  protected 
by  the  application  of  a  cotton  bandage,  without  pressure.  A 
local  application  of  a  lotion  suggested  by  Fuller  is  of  service: 

IJ  Sodium   carbonate  3vi 

Laudanum  ^i 

Glycerine  5" 

Water  ^ix 
M.  et.  ft.  Sol. 

The  application  of  analgesiquo  balm  (Benguo)  to  the  joints 
is  also  of  service  in  allaying  pain ;  other  remedies  suggested  are 
chloroform  liniment  and  mesotan. 

Internally  some  form  of  salicylic  acid  is  positively  indicated, 


326  THE   DISEASES  OP    CHILDREN. 

depending  upon  the  condition  of  the  stomach  and  its  tolerance. 
Fuller  also  recommends  -the  administration  of  alkaline  reme- 
dies, the  formula  suggested  being  as  follows: 

IJ  Sodii  salicylatis  3i 

Essentia  pepsin  ( N.  F. ) 

Aquae  dest.  q.s.   ad     f^ss 
M.  ft.  Sol. 
Sig.     One  teaspoonful  at  a  dose  at  two  hours  interval. 

Salophen  in  three  to  five  grain  doses  is  beneficial  also. 

Aspirin  in  3  to  5  grain  doses.  Salicin  in  3  grain  doses.  Sali- 
pirin  and  salophen  in  3  to  5  grain  doses. 

After  the  acute  symptoms  have  subsided,  one  of  these  prepa- 
rations should  be  given  for  a  week  or  more,  and  the  salicylate 
of  colchicum,  in  the  form  of  the  Pil.  Colchisal  (Fougera)  is  of 
great  benefit. 

For  the  pain  and  restlessness,  opium  in  some  form  may  be 
indicated,  Dover's  powder,  morphine,  codeine  or  heroin,  in  ap- 
propriate doses. 

Iron  for  the  anemia  in  the  convalescence  is  most  important, 
and  should  always  be  given  either  alone  or  with  cod  liver  oil. 
In  the  event  a  severe  heart  lesion  develops  the  application  of 
an  ice  bag  to  the  precordial  region  is  indicated.  This  allays  the 
pain  and  discomfort  of  breathing  and  limits  the  amount  of  per- 
manent involvement  of  the  valves.  Digitalis  should  be  employed 
only  when  indicated  by  failure  of  compensation,  always  judi- 
cioush'^  and  in  as  small  doses  as  possible," 

When  the  patient  is  allowed  to  get  up  flannel  underwear  or 
a  wool  and  cotton  mixture  must  be  worn  in  winter,  and  a  thin- 
ner cotton  underwear  in  summer,  being  careful  to  protect  from 
exposure  at  all  times. 

DIABETES  MELLITUS. 

Definition. — As  in  the  adult  this  is  a  disease  characterized  by 
a  polyuria  charged  with  sugar;  thirst  accompanied  by  wasting. 
It  is  not  a  frequent  condition  in  children,  but  is  rapidly  fatal 
in  the  majority  of  cases. 


GENERAL   DISEASES.  327 

Frequency. — Out  of  3014^  cases  394,  or  13  per  cent,  occurred 
in  children  under  15  years  of  age. 

Etiology. — It  occurs  infrequently  before  the  end  of  the  first 
year  and  more  often  between  5  and  10  years.  Sex  and  race 
have  little  part  in  the  causation,  though  slightly  more  females 
were  affected,  but  heredity  plays  a  decided  part  in  it.  Trauma, 
falls  or  blows  upon  the  head  have  been  suggested  as  a  contrib- 
uting cause.  Exposure,  tuberculosis,  the  infectious  diseases  and 
a  diet  too  rich  in  sugar  and  starches  begun  too  early  have  been 
mentioned  as  causes. 

Wilcox  -  found  excretion  of  sugar  in  the  urine  after  the  in- 
gestion of  from  15  to  20  grains  of  glucose,  and  concludes  that 
children  care  for  sugar  as  well  if  not  better  than  adults.  He 
puts  the  glucose  capacity  for  the  first  ten  years  as  30  to  60 
grains. 

Pathology. — Practically  nothing  of  a  definite  nature  is  known 
of  the  pathology  of  this  disease.  A  nephritis  is  often  present, 
parenchymatous  in  type.  The  pancreas  shows  a  variety  of 
changes,  atrophy  or  enlargement,  and  either  hard  or  soft,  con- 
gested or  normal.  Calculus  in  the  pancreatic  duct  has  been 
mentioned. 

Symptoms. — Frequent  urination  is  the  principal  symptom, 
with  progressive  and  often  rapid  loss  of  weight  in  spite  of  an 
increase  in  the  appetite.  The  increase  in  the  thirst  is  marked. 
Headache  may  be  a  prominent  symptom  and  the  child  may  be 
irritable  and  peevish,  and  there  is  usually  an  odor  of  acetone 
to  the  child's  breath  and  secretions.  The  skin  is  dry  and  harsh 
to  the  feel.     Loss  of  strength  is  in  proportion  to  the  emaciation. 

The  urine  is  abundant,  varying  from  700  to  7000  cc.  in  24 
hours,  clear,  and  of  a  high  specific  gravity,  and  contains  sugar 
and  frequently  albumen.  The  sugar  varies  in  amount  accord- 
ing to  the  time  of  day  it  is  examined,  lowest  at  night,  highest 
at  midday.  Hyaline  and  granular  casts  are  apt  to  be  present, 
and  have  been  considered  a  forerunner  of  coma.  Acetone,  dia- 
eetic  acid,  oxybutyric  acid  may  be  present  and  are  of  grave  sig- 
nificance. 

The  blood  shows  an  increase  in  sugar. 


1  Wilcox:   Archives   of    Pediatrics,    September,    1908. 
'  Loc.   cit. 


328  THE  DISEASES  OP    CHILDREN. 

The  duration  in  recorded  cases  varies  from  four  days  to  two 
years. 

The  child  which  may  have  been  able  to  retain  its  urine  all 
night  begins  to  have  enuresis  and  requires  frequent  changing 
both  day  and  night.  INIore  urine  is  passed,  usually  during  the 
day. 

Complications.— ri^wri^wcttZosis  frequently  occurs,  and  pruritus 
is  quite  common.  Tuberculosis  is  given  as  a  common  complica- 
tion. Diabetic  coma  is  the  usual  fatal  complication.  Its  fore- 
runner is  the  peculiar  sweetish  acetone  odor  to  the  breath,  a 
cessation  in  the  restlessness  and  increased  hebetude  and  tendency 
to  prolonged  sleep.  AVhen  the  coma  becomes  profound  its  dura- 
tion is  very  short  and  a  fatal  termination  prompt.  Cyanosis 
follows  the  irregular  breathing  which  soon  sets  in,  the  extremi- 
ties are  cold  and  pulse  weak  and  rapid. 

Diagnosis. — This  is  not  usually  made  early  because  of  the 
failure  to  make  urinalyses  promptly  in  children's  diseases.  The 
association  of  symptoms  should  cause  the  condition  to  be  sus- 
pected, viz.,  increase  in  the  urine,  thirst,  increased  appetite  and 
wasting,  and  an  examination  of  the  urine  to  be  made. 

Prognosis. — This  is  always  grave,  as  death  follows  very  soon 
after  a  diagnosis  is  made.  It  is  one  of  the  most  rapidly  fatal 
of  the  diseases  of  childhood.  The  progress  and  course  of  the 
disease  is  best  learned  by  the  amount  of  sugar  excreted,  quantity 
6f  acids  in  the  urine,  the  weight  and  amount  of  urine  passed 
in  24  hours. 

Treatment. — Breast  feeding  should  be  encouraged.  Endeavor 
to  find  which  form  of  carbohydrates  is  best  borne.  This  is 
learned  by  frequent  urinalyses  while  the  different  starches  are 
given.  The  presence  of  diacetic  acid  in  the  urine  is  an  evi- 
dence that  more  carbohydrate  is  needed.  Modified  milk  should 
be  rich  in  fat  content  if  no  special  acidosis  is  present,  and  sac- 
charin used  instead  of  the  sugar  for  carbohydrate  content.  In 
older  children,  mefit,  eggs,  green  vegetables,  animal  broths  and 
meat  juices. 

Dmgs  offer  but  little  hope  of  amelioration.  Codeine  sulphate 
is  the  onlj'  medicinal  treatment  of  value.  One  of  the  forms  of 
opium  can  be  tried  with  arsenic.     Benzosol  in  3  grain  doses  for 


GENERAL   DISEASES.  329 

its  effect  on  the  intestine  can  be  given.     For  the  acidosis,  the 
bicarbonate  of  soda  is  specially  indicated. 

TUBERCULOSIS. 

Etiology. — The  tubercle  bacillus  is  the  active  causative  agent 
of  tuberculosis.  Two  chief  characters  of  bacilli  are  described, 
the  human  and  the  hovine  types.  The  human  type  is  a  rod 
shaped,  colorless,  acid  fast  bacillus  with  rounded  ends,  and 
slightly  bent.  The  bovine  type  has  blunted  ends,  is  thicker  and 
oval  in  shape.  They  are  resistant  to  cold  but  are  destroyed  by 
heat  and  sunlight. 

Children  of  tubercular  parents  inherit  a  tendency  to  tuber- 
culosis. Other  contributory  causes  are  adenoids  and  enlarged 
tonsils ;  bad  hygiene ;  improper  feeding ;  prolonged  illness ;  over- 
crowding in  schools  and  homes. 

Pathology. — Every  organ  or  tissue  of  the  body  is  subject  to 
the  invasion  of  the  tubercle  bacillus.  These  may  be  localized 
in  individual  organs  or  there  may  be  general  dissemination  of 
them. 

Glands. — A  proliferative  inflammation  takes  place  in  the 
glands  of  the  body,  those  situated  near  the  most  frequent  port 
of  entry  of  the  infecting  organism  being  the  ones  most  actively 
affected,  viz.,  bronchial,  cervical  and  mesenteric.  The  bacilli 
are  carried  through  the  lymph  channels  direct  to  these  scaven- 
gers of  the  body.  The  following  changes  may  occur  in  the 
gland:  1.  Chronic  proliferation  of  the  gland  tissue,  enlarge- 
ment. 2.  Degeneration,  cheesy  or  fibroid.  3.  Abscess,  break- 
ing down  of  the  gland  due  to  infection  with  other  organisms. 
4.  Calcification. 

The  tendency  in  these  glands  is  to  hold  the  infection  as  a  local 
process,  and  is  an  evidence  of  the  leucoeytic  fight  being  waged, 
an  attempt  of  nature  to  prevent  a  general  infection  or  an  in- 
vasion into  more  vulnerable  areas. 

The  frequency  of  postmortem  findings  of  bronchial  lymph 
nodes  is  significant  of  the  possibility  that  the  tonsils  and  respira- 
tory mucous  membrane  are  most  often  the  port  of  entry. 

Intestines. — Tubercular  ulceration  here  is  the  same  as  from 
other  causes,  and  but  for  the  surrounding  glandular  involve- 


330  THE  DISEASES  OP    CHILDREN. 

nient  or  bacteriological  examination  would  go  unrecognized  as 
such.    The  typical  tubercle  of  the  mucosa  may  be  found. 

Meninges. — The  chief  changes  in  tubercular  meningitis  are 
to  be  found  at  the  base  along  the  vessels,  though  miliary  tu- 
bercles may  be  found  scattered  over  the  entire  pia.  The  in- 
flammatory exudate  may  be  quite  thick  and  over  the  entire  brain. 
The  younger  the  child  the  more  severe  the  inflammation. 

Kidney. — The  most  frequent  form  of  involvement  here  is  of 
the  pelvis  of  the  kidney,  the  bacilli  being  easily  demonstrated 
in  the  pus.  Care  should  be  taken  to  differentiate  the  tubercle 
bacillus  from  the  smegma  bacillus,  which  can  be  done  by  a  more 
lengthy  decolorization  period. 

Lungs. — The  lesions  of  tuberculosis  in  the  lungs  of  the  child 
are  much  like  those  in  the  adult.  "With  a  predominance  of  the 
lymph  nodes  around  the  bronchi  and  trachea.  The  process 
usually  begins  with  a  gland  as  a  nucleus,  and  spreads  baseward 
rather  than  toward  the  apex  as  in  the  adult. 

Port  of  Entry. — A  child  being  so  much  closer  to  the  floor  or 
ground  when  w^alking,  and  when  younger  being  on  the  floor  at 
play  frequently,  is  much  more  open  to  infection  from  dust, 
infected  toys  and  hands,  than  an  adult.  The  infection  may 
occur  through  the  mucous  membrane  of  the  tonsil,  even  though 
unbroken,  or  carried  directly  to  the  lungs  through  the  bronchi. 

The  intestinal  mucous  membrane  may  allow  the  bacilli  to  enter 
without  an  abrasion  being  present,  and  it  has  even  been  stated 
by  one  observer  that  pulmonary  infection  moi'e  frequently  oc- 
curred from  the  bacilli  gaining  entrance  through  the  intestine 
than  through  the  bronchi.  That  it  does  so  occur  is  proven  be- 
yond doubt.  Skin  abrasions  may  allow  the  entrance  of  the  ba- 
cilli. 

The  lesion  found  may  not  be  any  guide  to  locating  the  port  of 
entry. 

The  ingestion  of  the  bacillus  in  milk  is  a  positive  source  of 
infection.  Infected  milk  and  butter,  nipples,  toys,  the  mouth 
in  kissing,  dirt  under  the  nails,  are  also  conveyers  of  the  ba- 
cilli. 

Frequency. — During  the  first  year  less  frequent  than  after- 
Avard.     Schwer  found  14  per  cent  of  the  children  autopsied  be- 


GENERAL   DISEASES.  331 

tween  2  and  12  months  to  be  tubercular.  Cornet  published  re- 
sult of  analysis  or  records  of  Berlin  Pathological  Institute,  which 
showed  of  947  children  dying  between  1876-1891,  22  per  cent 
showed  tuberculosis ;  Still  found  35  per  cent  in  769  postmortems. 
The  greater  number  of  deaths  occur  between  two  and  four  years. 
Jacobi  and  others  have  reported  cases  of  fetal  tuberculosis. 

General  Symptoms. — The  development  of  tuberculosis  in  chil- 
dren may  be  very  insidious.  In  all  forms  the  child  shows  a  cer- 
tain departure  from  normal,  which  is  apparent  to  the  careful 
mother  or  nurse.  There  is  a  listlessness  or  heaviness  not  ascriba- 
ble  to  anything  else.  The  appetite  is  capricious  and  the  disposi- 
tion variable,  rather  an  inclination  in  sunny  temperaments  to 
tantrums  and  moodiness. 

There  is  a  beginning  pallor,  the  flesh  loses  its  firmness  and 
the  step  its  elasticity;  and  if  weighed  there  is  an  appreciable 
loss  in  body  weight. 

Unexplained  temperatures  are  frequently  found  to  be  due 
to  an  acutely  inflamed  ear  without  much  pain,  or  a  beginning 
involvement  with  tuberculosis. 

]\Iouth  breathing  is  frequently  a  prominent  symptom,  from 
a  collection  of  adenoids  in  the  nasopharynx,  the  tonsils  are  en- 
larged  and  the  nasopharynx  red.  Exhaustion  is  easily  produced, 
these  cases  having  but  little  endurance.  They  will  play  vig- 
orously for  a  short  while,  but  stop  suddenly,  lying  down,  per- 
haps, wherever  they  may  be,  often  complaining  of  being  tired. 

The  pulse  is  not  full,  usually  much  quickened  and  'irrita- 
ble."    Respiration  is  hurried,  especially  on  tha  least  exertion. 

Anemia  is  a  prominent  and  early  symptom,  shown  in  a  decided 
decrease  in  hemoglobin,  and  some  diminution  in  the  red  blood 
cells.  Very  acute  cases  show  less  blood  change  than  the  more 
chronic  ones. 

Clinical  Varieties. — The  special  symptoms  of  the  numerous 
clinical  types  of  tuberculosis  vary  according  to  the  region  or  or- 
gans affected.  The  general  symptoms  just  enumerated  are  more 
or  less  common  to  all  of  them. 

Glandular  Tuberculosis.  (Tubercular  Adenitis.) — Tubercu- 
lar enlargement  of  the  bronchial  lymph  nodes  may  never  be 
recognized  clinically,  but  at  autopsy  beginning  at  the  bifurcation 


332  THE  DISEASES  OP    CHILDREN. 

of  the  bronchi  the  glands  are  found  much  enlarged.  Cervical 
adenitis  is  comparatively  frequent.  To  differentiate  an  adenitis 
of  other  origin  may  be  difficult.  The  tubercular  gland,  however, 
usually  enlarges  slowly  but  continuously,  without  much  local  dis- 
turbance and  with  practically  no  pain  on  palpation.  As  the 
deeper  glands  enlarge  they  become  matted  together,  perhaps 
become  adherent  to  the  skin  and  form  large  irregular,  nodular 
masses.  They  may  remain  quiescent  for  varying  lengths  of 
time,  ending  in  caseation  or  pus  formation  with  discharge  of 
the  pus  through  a  fistulous  opening  which  may  require  surgical 
intervention.  The  subject  of  surgical  removal  of  tubercular 
glands,  especially  when  about  the  neck,  has  been  thoroughly  dis- 
cussed, with  a  preponderance  of  opinion  in  favor  of  noninter- 
ference. Dissemination  of  the  local  tuberculosis  into  a  general 
miliary  tuberculosis  has  been  ascribed  to  removal  of  glands  of 
the  neck. 

Appetite  is  very  changeable,  at  times  good,  at  others  very 
poor.     Sweets  are  usually  craved. 

TUBERCULAR  MENINGITIS. 

This  may  be  a  local  manifestation  of  tuberculosis  or  a  sequel 
to  an  infection  elsewhere. 

Etiology. — This  disease  is  due  to  a  direct  invasion  of  the 
meninges  by  the  tubercle  bacillus.  The  bacilli  may  localize  in 
the  meninges  as  a  primary  affection,  absorbed,  perhaps,  from  the 
nasal  mucous  membrane  direct ;  or  they  may  be  carried  through 
the  lymph  or  blood  from  tubercular  foci  elsewhere,  the  lungs, 
lymph  nodes,  joints,  abdomen,  etc.  Lack  of  resistance  from 
previous  illnesses  is  usually  present  as  a  determining  factor. 
There  may  be  a  history  of  previous  attacks  of  enterocolitis,  per- 
tussis, bronchitis,  bronchopneumonia,  the  exanthemata,  middle- 
ear  disease,  from  which  the  child  never  fully  recuperated. 

Age  is  an  important  factor  in  the  etiology.  Children  are 
much  more  often  affected,  especially  between  the  ages  of  two  and 
ten,  the  average  age  being  about  four  years. 

Pathology. — The  pathological  changes  vary  greatly.  Autopsy 
findings  may  be  very  slight  in  the  severe  and  rapidly  fatal  cases, 
and  the  protracted  ones  may  show  severe  lesions. 


GENERAL.   DISEASES. 


333 


The  brain  may  show  changes  which  vary  from  a  few  scattered 
grayish  tubercles  along  the  vessels  in  the  fissure  of  Sylvius,  to  a 
thick,  inflammatory  exudate  over  the  entire  base.  The  effusion 
may  be  thin  and  seropurulent,  and  extend  into  the  fissures  of 
the  brain  and  well  up  on  to  the  convexity.  Accumulation  of 
fluid  in  the  ventricles  is  usually  found,  distending  them  fully. 


Fig.    61. 


Fig.    62. — Temperature    for    81    days    in    child    with    general    tuberculosis,    ending    in 
tubercular    meningitis. 

The  process  may  extend  into  the  cord.  The  pia  mater  is  infil- 
trated. 

The  lungs  may  show  unresolved  areas  of  pneumonia,  perhaps 
with  cheesy  disintegration,  the  hronchial  glands  are  also  en- 
larged and  some  broken  do\\Ti  or  softened.  The  mesenteric 
glands  are  usually  enlarged,  perhaps  disintegrated  or  softened. 
The  superficial  lymph  nodes  may  be  found  enlarged,  also  the 
tonsils. 

Symptoms. — But  few  diseases  present  so  varied  a  picture  at 
the  onset  as  tubercular  meningitis,  and  in  consequence  the  diag- 
nosis in  the  majority  of  cases  is  not  made  during  the  early 


SS"!  THE   DISEASES   OF    CHILDREN, 

The  onset  is  practically  always  insidious  except  in  a  very  few 
cases  in  which  convulsions  may  usher  in  the  attack.  For  a  very 
varying  length  of  time  the  child  is  not  normal,  is  listless  and 
peevish,  not  inclined  to  play,  restless  at  night,  no  appetite,  and 
if  old  enough  may  complain  of  headache.  Nausea  may  be  pres- 
ent with  slight  gastrointestinal  disturbance,  sufficient  to  look 
upon  it  as  the  cause  of  the  indisposition.  There  is  a  slight  rise 
of  temperature,  not  much  more  than  100.5°  F.,  more  or  less 
continuous  and  without  decided  remissions.  In  one  case  seen 
in  an  adjoining  city  recently,  because  of  the  fever,  a  tentative 
diagnosis  had  been  made  of  malaria,  and  later  of  typhoid  fever. 
After  a  few  days  the  vomiting  may  be  a  prominent  symptom, 
recurring  often  and  without  provocation.  Constipation  is  the 
rule  in  this  stage. 

After  a  varying  length  of  time,  rarely  longer  than  two  weeks, 
the  signs  of  acute  inflammation  take  place,  and  the  diagnosis  is 
plain.  There  is  a  rise  in  the  temperature  to  101°  F.  or  103°  F. 
I  have  not  seen  the  temperature  very  much  above  104°  F.  in 
this  form  of  meningitis,  though  106°  F.  has  often  been  reported. 
Before  this  time  the  patient  could  be  roused,  often  with  diffi- 
culty, but  from  now  on  there  is  more  or  less  deep  stupor,  from 
which  it  cannot  be  roused.  It  will  swallow  when  liquids  are 
placed  between  the  teeth,  but  later  cannot  do  this. 

At  the  beginning  of  this  stage,  for  a  brief  period  usually,  the 
characteristic  symptom,  Cheyne-Stokes'  respiration  takes  place. 
In  two  of  my  cases  recently,  this  symptom  was  present  early 
in  the  inflammatory  stage  for  24  hours  and  disappeared,  re- 
turning a  few  hours  before  death  in  one  of  them. 

The  pulse  is  very  variable,  at  times  rapid,  at  others  slow,  be- 
ing also  irregular  in  volume. 

Vasomotor  phenomena  are  present,  alternate  flushing  and 
blanching  of  the  cheeks,  and  the  tacJie  cerehrale  is  usually  pres- 
ent at  this  time. 

The  abdomen  is  retracted,  as  a  rule,  giving  the  typical 
''scaphoid  belly."  The  pupils  are  usually  unequally  dilated 
and  fixed,  though  they  may  be  equal.  The  conjunctival  reflex 
is  absent  and  a  squint  may  be  present. 


GENERAL   DISEASES.  335 

There  may  be  general  convulsions  at  this  stage,  or  only  slight 
convulsive  movements  of  the  facial  muscles  and  the  extremities. 
Rigidity  of  the  neck  usually  develops  early,  and  as  the  disease 
progresses  there  may  be  opisthotonos  more  or  less  marked. 

From  this  time  the  child  develops  into  the  stage  of  coma;  the 
pulse  is  very  rapid,  the  respirations  shallow  and  irregular,  the 
sphincters  relaxed.  The  temperature  just  before  death  may 
rise  very  rapidly,  but  usually  does  not. 

Kernig's  sign  and  the  Babinski  reflex  are  found  in  perhaps 
the  majority  of  cases. 

Death,  which  is  inevitable,  may  be  preceded  by  general  con- 
vulsions. 

The  duration  is  very  varied,  lasting  from  one  to  six  weeks, 
with  an  average  of  perhaps  three  weeks. 

Diagnosis. — The  chief  aid  in  the  diagnosis  of  the  form  of 
meningitis  present  is  a  consideration  of  the  previous  personal 
and  the  family  history  of  the  child. 

Acute  meningitis  usually  develops  suddenly,  and  all  of  the 
symptoms  are  more  acute  from  the  onset,  shorter  in  duration, 
and  Avith  higher  temperature. 

The  low,  continuous  fever  is  suggestive  of  typhoid,  and  in 
suspicious  cases  the  AVidal  and  diazo  tests  should  be  made,  and 
if  still  uncertain  at  the  end  of  the  second  week,  repeated. 

Lumbar  puncture  may  be  of  great  assistance  in  clearing  up 
the  diagnosis  (see  page  516).  The  fluid  is  then  examined  for  the 
tubercle  bacilli,  pneumococci,  staphylococci,  etc.  It  usually 
escapes  under  increased  pressure. 

Prognosis. — The  positive  diagnosis  of  a  case  of  tubercular 
meningitis  is  the  equivalent  of  signing  the  death  certificate  in 
advance.  If  a  case  of  meningitis  recovers  in  which  the  clinical 
diagnosis  of  the  tubercular  form  has  been  made,  without  isola- 
tion of  the  bacilli  in  the  spinal  fluid,  the  original  diagnosis  was 
in  error. 

Treatment. — This  is  purely  symptomatic,  and  of  no  avail  as 
far  as  a  cure  is  concerned.  Chloroform  for  control  of  the  con- 
vulsions, with  bromides  and  chloral ;  liquid  diet ;  ice  bag  to  head 
and  spine;  stimulants  when  indicated,  absolute  quiet,  etc. 


336  THE   DISEASES   OF   CHILDREN. 

TUBERCULAR  PERITONITIS. 

While  comparatively  rare,  in  children,  this  variety  of  peri- 
tonitis is  seen  in  children.  The  bacillus  may  find  original  lodg- 
ment in  the  peritoneum  but  is  more  often  transported  from 
mesenteric  lymph  nodes  or  other  more  remote  port  of  entry. 

Pathology. — Several  forms  are  described,  the  ulcerating  form 
in  which  the  intestines  are  matted  together  and  adherent,  the 
fibrinous  form  in  which  the  intestines  are  covered  with  a  thick, 
purulent  exudate  through  which  are  seen  the  miliary  tubercles, 
and  a  matting  together  of  the  intestines,  and  the  miliary  form 
with  ascites.  There  are  numerous  miliary  tubercles  scattered 
over  the  intestine  and  parietal  peritoneum,  a  serous  or  sero- 
purulent  fluid  escapes  on  incision  of  the  abdomen  in  which  float 
flecks  of  fibrin.  Numerous  adhesions  are  present  both  of  coils 
of  the  intestines  to  each  other  and  to  the  parietal  peritoneum. 

Symptoms. — The  miliary  form  with  ascites  is  most  frequent 
in  children,  and  the  diagnosis  is  usually  not  made  early  because 
of  the  insidiousness  of  the  onset.  There  may  be  a  few  indefinite 
digestive  disturbances  with  moderate  rise  of  temperature,  per- 
haps some  pain  in  the  abdomen,  followed  sooner  or  later  by  grad- 
ual enlargement  of  the  abdomen  from  accumulated  fluid.  The 
appetite  is  variable,  the  bowels  irregular  with  occasional  attacks 
of  vomiting.  Before  the  abdomen  becomes  tense  from  accumu- 
lated fluid  careful  examination  may  reveal  nodules  and  enlarged 
mesenteric  glands.  Percussion  of  the  abdomen  in  changed  po- 
sition may  show  the  line  of  fluid,  fluctuation  can  also  be  obtained. 

Treatment. — Surgery  offers  the  best  results  in  the  ascitic  form. 
An  incision  should  be  made  through  the  abdominal  wall,  with 
evacuation  of  the  fluid  and  immediate  closure,  wdthout  drain- 
age. After  convalescence  from  the  operation,  the  patient  should 
have  fresh  air,  judicious  feeding,  quiet,  cod  liver  oil  and  other 
tonics  as  indicated. 

With  the  development  of  pathologic  changes  in  the  lungs 
symptoms  referable  to  this  region  appear.  Cough,  without  ex- 
pectoration, except  in  much  older  children,  as  the  young  always 
swallow  material  raised  from  the  bronchi  or  trachea.  If  pleurisy 
is  present,  there  is  usually  pain  and  friction  sounds  over  the 


GENERAL   DISEASES.  337 

area  involved,  and  an  examination  will  show  signs  peculiar  to 
the  stage  of  the  degeneration.  Bronchial  glands  may  give 
impaired  resonance  or  high-pitched  breathing,  if  constricting 
either  or  both  bronchi.  If  the  process  has  been  engrafted  upon 
an  unresolved  pneumonia,  the  pneumonic  signs  persist  with 
addition  of  signs  of  degeneration,  localized  fine,  moist  rales, 
with  approach  to  cavernous  breathing  as  breaking  down  occurs. 
Pulmonary  hemorrhage  is  quite  uncommon  in  children.  The 
following  history  is  a  typical  one  of  acute  tuberculosis  in  a 
child : 

L.  H.,  nine  years  old,  was  first  admitted  to  the  Masonic  Home  January 
22,  1895,  the  physician's  certificate  stating  that  both  parents  had  died  of 
phthisis  pulmonalis. 

Examination  on  admission  showed  hypertrophied  tonsils,  necrosed  molar 
teeth  and  a  peculiar  listless  expression. 

For  some  weeks  after  admission  it  was  noticed  that  she  was  dull  and 
apathetic,  having  little  to  do  with  the  other  children,  apparently  preferring 
to  be  alone.  She  had  peculiar,  expressionless  eyes,  with  slight  divergent 
strabismus  of  the  left  one. 

She  was  admitted  to  the  infirmary  on  the  14th  of  April,  having  had  a 
chill  on  the  previous  day.  She  was  given  9  grains  of  quiniae  sulphas,  daily 
for  five  days,  after  receiving  1  grain  of  calomel  on  the  first  day,  with  no 
effect  upon  the  temperature.  Examination  at  this  time  showed  her  to  be 
very  anemic  and  much  thinner  than  on  admission.  She  was  content  to 
lie  quiet  for  hours,  with  a  vacant  stare,  but  would  answer  questions  in 
monosyllables,  never  venturing  a  remark  or  making  her  wants  known. 

On  May  20  the  following  notes  were  made:  Very  pale,  much  wasting 
since  admission;  glands  of  neck,  anterior  and  posterior,  submaxillary  and 
sublingual  markedly  enlarged,  some  to  size  of  hazel  nuts,  some  larger. 
Inguinal  glands  slightly  enlarged  to  about  the  size  of  a  pea.  Abdomen 
relaxed.  No  mesenteric  enlargements  made  out.  Harsh  breathing  found 
over  posterior  aspect  of  chest,  otherwise  negative.  Some  faucial  congestion 
witli   tonsillar   enlargement. 

Diagnosis  of  general  tuberculosis  with,  perhaps,  beginning  tubercular 
meningitis.  On  May  23  she  was  seen  by  the  consulting  staff,  the  diagnosis 
of  general  tuberculosis  being  concurred  in. 

She  was  put  on  nourishing  diet  and  tonic  treatment.  Slie  would  not  stay 
out  of  bed,  and  gradually  grew  weaker  from  day  to  day. 

From  June  23  she  complained  continuously  of  severe  headache,  crying 
out  with  pain. 

On  July  1  she  had  a  general  convulsion,  contractions  of  flexor  muscles 
of  arms  and  legs  being  present  for  some  time.  Both  pupils  were  dilated 
equally.     Large  doses  of  potassium  bromide  were  given  without  effect. 


338  THE   DISEASES   OF    CHILDREN. 

During  the  night  of  July  1  she  had  many  general  convulsions,  lasting  two 
or  three  minutes.  During  the  morning  of  the  2nd  day  she  lay  in  a  stupor, 
perfectly  relaxed;  she  coughed  considerably;  the  pupils  were  equal  and  the 
pulse  regular.     She  died  quietly  at  3  p.  ra. 

Autopsy.  On  the  morning  of  the  next  day,  18  hours  after  death.  RigQr 
mortis  marked.     Body  much  emaciated. 

Chest.  Lungs.  Tubercular  nodules  and  patches  of  tubercles  distributed 
over  the  surface  and  borders  of  both  lungs.  Slight  hypostatic  congestion. 
Section  shows  apices  thickly  studded  with  tubercular  nodules.  Bronchial 
glands  enlarged  and  in  a  state  of  fibrous  degeneration,  not  cheesy.  Most 
marked  enlargement  of  glands  at  bifurcation  of  trachea  and  along  primary 
bronchi.  Ko  pleural  adhesions.  Heart  and  pericardium  normal.  A  lum- 
bricoid  worm  6  inches  in  length  was  found  in  the  esophagus. 

Aidomen.  Peritoneum  and  mesentery  thickly  studded  with  tubercles. 
Mesenteric  glands  enlarged  and  fibrous.  Appendix  vermiformis  3  inches 
long,  lying  in  the  right  iliac  region. 

Head.  An  excess  of  cerebrospinal  fluid  on  opening  calvarium.  Dura, 
normal.  Brain  (macroscopic  examination  by  Dr.  Carl  Weidner)  is  large, 
symmetrical.  The  pia  mater  is  rather  firm.  It  is  cloudj',  in  some  portions 
distinctly  yellowish,  both  at  the  convexity  and  at  the  base.  At  the  vertex 
it  can  be  detached  without  any  difficulty.  At  the  base  it  is  markedly 
adherent  in  places,  and  especially  so  at  the  fissure  of  Sylvius.  These 
adhesions  are  quite  firm.  In  addition  the  pia  shows  some  minute  whitish- 
yellow,  cloudy  spots,  and  similar  granules  at  the  base  of  the  anterior  lobes, 
also  an  increased  vascularity.  Along  the  superior  longitudinal  fissure 
there  are  an  unusually  large  number  of  Pacchinian  granulations. 

The  lateral  ventricles  having  been  torn  open  on  a  level  with  the  corpus 
callosum  (in  transportation  over  rough  streets  after  removal)  contained 
no  fluid.  The  cavities  seemed  large.  No  signs  of  disease  at  the  large 
basal  ganglia. 

The  medulla  and  cerebellum  showed  nothing  abnormal. 

The  case  is  reported  principally  on  account  of  the  interest  at- 
tached to  it  in  connection  with  the  temperature  chart,  a  record 
of  the  80  days  of  acute  trouble.     (Fig.  62.) 

Diagnosis. — AVith  the  ordinary  methods  employed  diagnosis 
of  tuberculosis  is  at  times  a  most  difficult  thing.  Any  contin- 
uous, irregular  fever,  in  a  child  presenting  the  symptoms  enu- 
merated above,  especially  anemia,  loss  of  appetite  and  strength, 
which  cannot  be  otherwise  explained,  is  verj^  suggestive  of  tuber- 
culosis. This  is  especially  true  when  there  has  been  a  history 
of  exposure.  I  have  recently  had  under  my  observation  a  child 
in  whom  tuberculosis  was  strongly  suspected  because  of  a  per- 


GENERAL   DISEx\SES.  339 

sistent  temperature  which  was  later  found  to  be  due  to  an  in- 
volvement of  the  middle  ears. 

The  use  of  tuberculin  for  diagnostic  purposes  has  recently 
been  proven  of  great  service.  It  can  be  employed  in  the  form 
of  a  subcutaneous  injection  of  the  original  tuberculin  (Koch), 
by  the  conjunctival  or  the  Calmette  method,  and  by  the  cutane- 
ous method  of  von  Pirquet. 

In  the  ophthalmic  test  the  solution  used  is  prepared  as  follows : 

The  tuberculin  is  precipitated  by  the  addition  of  95  per  cent 
alcohol  to  concentrated  T.  O.,  or  Tuberculin  Original  (Koch). 
The  precipitate  is  collected  on  filter  paper  and  washed  with 
70  per  cent  alcohol  until  the  filtrate  runs  clear.  It  is  dried  in 
vacuo  over  II0SO4  and  afterwards  ground  into  a  powder.  The 
powder  is  dissolved  in  sterile  normal  saline  solution  of  1  per 
cent  by  weight,  heated  in  a  water  bath  and  filtered  through 
paper.  It  is  diluted  as  desired  and  filled  into  capillary  glass 
tubes,  which  is  then  sealed  and  boiled  for  10  minutes  in  a 
water  bath.  This  insures  a  perfectly  sterile  solution,  being 
instilled  into  the  eye. 

Two  solutions  are  employed  in  order  to  avoid  unnecessarily 
severe  reaction.  No.  1  contains  0.5  per  cent,  and  No.  2,  1  per 
cent.  The  No.  1  solution  is  used  in  one  eye,  and  if  no  reaction 
is  obtained  in  48  hours  No.  2  solution  is  used  in  the  other  eye. 
It  is  quite  possible  that  the  unpleasant  effects  reported  in  some 
cases  is  due  to  a  too  strong  solution.  Brown  advises  a  1 :250 
solution  in  one  eye  and  1 :100  solution  in  opposite.  The  method 
of  application  is  as  follows :  One  end  of  the  capillary  tube 
holding  the  solution  is  passed  through  the  small  rubber  bulb, 
and  a  minute  portion  of  both  ends  is  broken  off,  and  the  tube 
slipped  back  into  the  bulb.  The  end  of  the  tube  from  which 
the  drop  to  be  expelled  is  carefully  wiped  with  sterile  gauze 
or  cotton  to  remove  any  spicule  of  glass.  The  lower  lid  is  held 
down,  and  by  holding  the  tube  parallel  with  the  eye  1  drop 
from  the  tube  can  be  squeezed  on  to  the  mucous  membrane  at 
the  outer  canthus.  The  lid  is  so  held  as  to  form  a  sac,  the  solu- 
tion being  evenly  distributed  over  the  lid  without  allowing  it 
to  overflow  on  to  the  cheek.     Occasionally  a  very  slight  smarting 


340  THE  DISEASES  OP   CHILDREN. 

sensation  is  complained  of,  but  this  is  momentary.  It  is  ad- 
visable to  warm  the  tubes  to  body  temperature  if  they  have 
been  kept  in  a  eool  place.  The  tested  eye  should  be  protected 
from  external  irritation,  rubbing,  wind,  dust  or  smoke. 

The  reaction  described  by  Calmette  is  seen  on  an  average 
at  about  seven  hours  after  the  inoculation,  though  it  may  be 
delayed  for  24  hours  or  even  48  hours.  The  first  sensation 
is  that  of  a  scratchy  feeling,  lacrimation  and  redness,  to  a  more 
severe  one  of  severe  injection  of  the  conjunctiva  and  swelling 
of  the  lids.  A  stuffiness  of  the  nostrils  on  the  corresponding  side 
accompanied  by  a  slight  coryza.  Park  suggests  the  following 
classification  of  reaction: 

0  Negative:  No  difference  in  the  color  when  lower  lids  are 
pulled  down. 

'?  Doubtful:  Slight  difference,  with  redness  of  caruncle. 

-\-  Positive:  Distinct  palpebral  and  ocular  redness,  with 
secretion  well  marked. 

-j-+  Deep  injection  of  entire  conjunctiva  with  edema  of  lids, 
photophobia  and  secretion. 

The  reaction  may  continue  for  a  week  and  gradually  subside. 
In  a  small  percentage  of  cases  there  is  a  slight  rise  in  tempera- 
ture, but  this  is  not  often  high. 

Both  eyes  should  be  closely  examined  before  the  inoculation 
to  be  certain  there  is  no  redness  present.  The  presence  of  a 
distinct  disease  of  the  eye  or  lid  is  a  contraindication  for  its  use, 
as  conjunctivitis,  blepharitis,  tBachoma,  iritis  and  keratitis.  If 
a  marked  reaction  is  noted,  the  conjunctivitis  can  be  controlled 
by  the  use  of  a  boracic  acid  solution  wash,  or  a  2  per  cent 
cocaine  solution  with  or  without  a  drop  of  a  1 :1000  solution  of 
adrenalin. 

The  cutaneous  method  of  diagnosis  consists  in  a  scarification 
like  an  abrasion  for  vaccination  against  smallpox,  under  the 
drop  of  tuberculin  after  the  method  suggested  by  von  Pirquet. 
Two  abrasions  are  made,  about  an  inch  apart,  one  being  used 
for  control,  the  control  abrasion  being  made  under  a  drop  of 
50  per  cent  glycerine  and  .1  per  cent  phenol  in  normal  salt 
solution.     Koch's  original  tuberculin  is  used,  diluted  with  one 


GENERAL  DISEASES.  341 

part  of  a  5  per  cent  carbol-glycerine  solution,  and  two  parts  of 
normal  saline  solution. 

Wolff-Eisner  describes  the  reaction  in  the  cutaneous  test  as 
follows:  The  early  reaction  occurs  in  about  three  hours,  be- 
ginning with  slight  redness  which  reaches  its  height  in  24  hours, 
and  has  faded  largely  in  48  hours.  In  a  few  hours  a  papule 
appears,  more  plainly  felt  than  seen,  and  in  very  occasional 
cases  a  bleb  is  formed. 

In  the  late  reaction  the  redness  and  papule  may  be  delayed 
until  the  fourth  day,  or  increase  gradually  until  the  fourth  or 
fifth  day,  and  may  persist  for  three  or  four  weeks.  Enlarge- 
ment or  tenderness  of  the  glands  in  the  axilla  may  be  present. 
The  reaction  is  described  in  this  form  as  the  normal  reaction 
of  the  tuberculous  individual;  the  late  reaction,  which  may  be 
marked  strong  or  unusually  strong;  the  quick,  but  very  weak 
and  fleeting  reaction  which  may  be  overlooked. 

The  suhcutaneom  method  consists  in  the  injection  of  1/10 
mg.  of  the  original  tuberculin  (Koch).  If  there  is  no  reaction 
following  its  initial  administration,  a  second  dose  may  be  given 
after  a  lapse  of  two  or  three  days,  gradually  increasing  by  1/10 
mg.  doses  up  to  3  or  4  mg.  Brown  advises  giving  the  injection 
at  night,  when,  in  a  majority  of  instances,  the  reaction  occurs 
in  8  to  20  hours.  It  may  occur  in  four  or  five.  Late  reactions, 
second  or  third  day  have  been  noted.  On  this  account  the 
injection  should  be  given  every  third  day.  A  "reaction"  is 
evidenced  by  "pain,  tenderness,  redness  and  swelling  at  the  site 
of  the  injection,  headache,  malaise,  an  increased  tendency  to 
cough,  probably  more  or  less  expectoration  than  usual,  and  at 
times  some  gastrointestinal  symptoms  as  nausea  and  vomiting." 
There  may  be  a  rise  in  temperature  also,  and  if  this  amounts 
to  2°  F.  it  is  fairly  characteristic. 

The  Mow  reaction  is  obtained  by  using  a  50  per  cent  oint- 
ment of  tuberculin  and  lanolin.  A  piece  of  this  the  size  of  a 
pea  is  rubbed  into  the  axilla.  In  24  or  48  hours,  in  the  presence 
of  tuberculosis  an  eruption  of  macules  and  papules  appear 
which  persist  upwards  ot  a  week. 

Owing  to  the  unfavorable  reports  of  the  ophthalmoreaction. 


342  THE   DISEASES   OP    CHILDREN. 

which  are  becoming  more  numerous,  the  cutaneous  or  vaccina- 
tion method  is  recommended  as  the  most  desirable  test. 

The  laboratory  is  an  aid  to  diagnosis  of  this  condition  in 
children,  but  owing  to  the  infrequent  successful  attempts  at 
obtaining  a  sample  of  sputum,  and  the  difficulty  of  finding  the 
bacilli  in  the  feces,  it  is  not  as  frequent  an  aid  as  might  be 
hoped  for.  By  closely  examining  the  blood  and  mucus  in  sus- 
pected intestinal  tuberculosis  the  bacilli  may  be  found.  In 
malaria  or  typhoid  fever  the  organism  peculiar  to  these  condi- 
tions may  be  found. 

In  tubercular  pyelitis  and  cystitis  the  bacilli  may  be  isolated. 
The  smegma  bacillus  must  be  differentiated  in  the  urinary  ex- 
amination, the  urine  being  obtained  by  catheterization  per- 
formed in  the  most  aseptic  manner. 

Blood  examination  may  show  in  the  early  stages  an  increase 
in  the  polymorphonuclear  cells,  later  the  mononuclears  may 
predominate. 

Prevention. — Prevention  of  tuberculosis  in  infancy  is  most 
important.  The  source  of  milk  supply  must  be  known,  and 
only  certified  milk  and  inspected  butter  used. 

A  child  should  never  be  allowed  to  come  in  contact  with  a 
consumptive,  or  to  visit  a  house  in  which  it  is  known  there  is 
a  consumptive.  Kissing  children  in  the  mouth  should  never 
be  permitted. 

Treatment. — The  same  general  principles  of  treatment  of  tu- 
berculosis in  children  should  be  instituted  as  are  employed  in 
adults.  If  a  sanitarium  is  possible,  it  will  be  found  very  easy 
to  adapt  a  child  to  the  routine  sanitarium  life.  Children  do 
not  stand  well  either  a  very  cold  climate  or  a  warm,  enervating 
one.  Absolute  rest  in  bed,  in  the  open  air,  should  be  insisted 
upon  at  first,  and  exercise  allowed  very  moderately  and  care- 
fully. This  treatment  is  indicated  in  surgical  tuberculosis  as 
well. 

Children  stand  forced  feeding  when  properly  instituted,  very 
well,  indeed,  milk  and  eggs,  being  the  best  borne  for  the  extra 
diet.  Only  "Certified"  milk  should  be  given  when  it  is  ob- 
tainable, if  not  the  milk  should  be  carefully  Pasteurized. 

The  original  tuberculin  is  used,  the  dosage  varying  accord- 


GENERAL   DISEASES.  343 

ing  to  the  patient  and  its  age,  1/12000  to  1/8000  mg.  for  a  child 
of  one  year  of  age. 

The  beneficial  effect  of  tuberculin  could  be  substantiated  by 
a  number  of  reported  cases. 

Medication  is  of  secondary  importance  to  a  carefully  regu- 
lated diet.  Tonics  undoubtedly  have  their  indication,  M'hen 
judiciously  employed,  especially  when  there  is  a  failure  of 
appetite  or  a  disgust  for  food.  Cod  liver  oil  can  frequently  be 
taken  either  pure  or  in  emulsion  to  great  advantage.  Iron,  the 
carbonate,  citrate  or  muriated  tincture,  syrup  of  the  iodide, 
diast  iron,  will  be  found  of  benefit.  Preparations  of  malt  may 
often  be  used  to  advantage. 

Baths  followed  by  a  general  rub  with  olive  oil  or  cod  liver 
oil  in  the  poorly  nourished  are  most  beneficial  remedies. 

The  importance  of  life  in  the  open,  especially  for  those  chil- 
dren living  in  the  close  quarters  of  the  poorer  classes,  cannot 
be  overestimated.  Open  air  schools  for  the  tubercular  child 
or  the  child  who  shows  a  tendency  to  a  tubercular  diathesis 
have  been  most  successful.  Proper  attention  to  clothing,  rest, 
and  food  for  the  child  in  the  open  air  school  is  necessary  for 
good  results. 

PELLAGRA.^     (Pelle,  skin;  Agra,  rough.) 

This  is  a  disease  which  prevails  in  the  Southern  States,  not- 
ably North  Carolina,  South  Carolina,  Mississippi,  Alabama  and 
Texas. 

It  is  a  toxemia,  supposed  to  be  directly  due  to  eating  damaged 
corn,  and  is  manifested  by  disorders  of  the  nervous  system,  di- 
gestive system  and  localized  erythemas  of  the  skin. 

Pellagra  has  been  known  since  1755,  the  first  cases  occurring 
in  Spain,  followed  by  others  in  Italy,  France  and  Egypt.  It 
has  occurred  in  South  America  and  Mexico,  and  in  this  country 
in  Alabama,  at  the  ]\It.  Vernon  Insane  Asylum,  first  reported 
.by  Dr.  Searcy  in  1906.  Since  this  time  many  other  cases  have 
been  seen. 

Etiology. — Eating  damaged  corn  is  believed  to  be  the  direct 
cause  of  this  disease.     Bad  hygienic  surroundings  and  ins.uflfi- 

*  I  am  indebted  to  the  writings  of  Dr.  Geo.  H.  Searcy,  Tuscaloosa,  Ala.,  for 
much  of  the  data  of  this   chapter. 


344 


THE   DISEASES   OF    CHILDREN. 


cient  nourishment  of  other  kinds  are  contributory  causes.  Corn 
is  usually  consumed  in  the  South  as  cornmeal  and  grits,  and 
these  when  moulded,  contain  fungi  and  bacteria.  Searcy  likens 
the  condition  under  discussion  to  gangrenous  ergotism,  and  be- 
lieves the  smut  (ustilago)  resembles  the  ergot  of  rye  very  much, 
and  that  corn  smut  is  the  cause  of  pellagra. 

The  direct  action  of  the  sun's  rays  is  believed  to  be  a  con- 
tributing cause  of  the  skin  lesions  of  pellagra,  these  occurring 
chiefly  upon  the  exposed  parts  of  the  body. 

Symptoms. — Cases  of  pellagra  are  either  acute  or  chronic. 

The  first  symptoms  of  the  acute  form  are  a  marked  lassitude 
and  weakness,  followed  by  loss  of  flesh  and  varied  gastrointes- 


Fig.    63.- 


-Pellagrous   dermatitis;    dry   form,    with   exfoliation   of   the   skin. 
Pellagra. ) 


(Roberts: 


tinal  symptoms.  The  duration  of  this  stage  may  be  some  weeks. 
The  acute  symptoms  begin  by  a  salivation  and  symptoms  of  indi- 
gestion, perhaps  pain  and  tenderness  in  the  epigastric  region, 
followed  by  diarrhea. 

The  skin  lesions  develop  about  this  time,  chiefly  the  exposed 


GENERAL   DISEASES.  345 

parts  of  the  body  being  affected,  limited  to  the  extensor  surfaces 
of  arm  and  hand,  dorsum  of  feet,  face  and  neck.  The  lesions 
are  symmetrical.  The  appearance  of  the  skin  is  a  deep  red, 
and  a  decided  anesthesia  in  the  part  affected.  The  affected 
skin  either  forms  bullae  and  blebs  or  becomes  scaly  and  thick- 
ened. If  the  vesicles  form  they  rupture  and  leave  a  denuded 
area  which  is  moist.  The  nervous  symptoms  are  soon  manifest, 
not  so  marked  in  the  early  acute  stage  as  when  the  disease  be- 
comes chronic.  The  chief  mental  symptom  is  a  depression 
which  grows  more  marked  if  the  case  becomes  chronic.  There 
is  pain  and  tenderness  in  the  dorsal  region  close  to  the  spine, 
with  exaggeration  of  the  patellar  reflexes.  Later  the  reflexes 
are  either  lessened  or  absent.  Insomnia  is  a  marked  feature 
from  the  beginning. 

The  temperature  may  be  elevated  a  degree  or  two,  but  is 
more  often  subnormal. 

The  acute  cases  may  prove  fatal  in  a  few  days  after  they  have 
to  go  to  bed ;  may  lapse  into  a  chronic  condition  or  may  recover. 
If  recovery  takes  place  the  improvement  is  slow:,  taking  several 
months  to  return  to  normal. 

In  the  chronic  form  there  may  be  a  history  of  an  acute  attack 
shortly  before,  or,  as  is  more  common,  an  attack  during  the 
previous  summer.  The  skin,  which  has  been  the  site  of  the 
eruption,  is  thick,  wrinkled  and  scaly. 

The  pronounced  mental  symptoms,  depression  and  melan- 
cholia, usually  do  not  become  noticeable  for  a  year  or  more,  but 
as  the  disease  progresses  the  mental  symptoms  are  so  severe  as 
to  necessitate  confinement  of  the  patient  in  an  asylum.  Demen- 
tia is  the  usual  final  outcome. 

Contractures  of  fingers  and  even  of  arms  or  legs  are  common 
late  in  the  disease. 

Diagnosis. — The  association  of  the  following  symptoms  is 
sufficient  to  make  the  diagnosis:  Location  of  erythema,  vesicles, 
etc.,  on  the  extensor  surfaces  of  the  exposed  parts  of  the  body ; 
salivation,  stomach  disturbances  and  diarrhea ;  mental  depres- 
sion, and  the  history  of  the  corn  diet. 

Pathology. — Fatty  degeneration  of  the  internal  organs ;  pachy- 
meningitis and  degeneration  of  the  posterior  nerve  roots  and 


346  THE   DISEASES   OF    CHILDREN. 

posterior  columns  of  the  cord,  and  in  the  dorsal  region,  in  the 
lateral  columns,  and  the  changes  in  the  skin.  There  is  also 
anemia  and  emaciation. 

General  atrophy  of  muscles  of  body  and  the  walls  of  the 
stomach  and  intestines  take  place  in  the  chronic  cases. 

Prognosis. — A  mortality  of  58  per  cent  was  reported  at  the 
Mt.  Vernon  Hospital.  Death  usually  occurs  within  three  weeks 
of  the  time  the  patient  goes  to  bed.  When  recovery  takes  place 
it  is  slow. 

Treatment. — The  principal  treatment  is  dietetic.  Remove 
from  the  list  of  food  all  corn  in  any  form.  Give  animal  broths 
and  milk.     Do  not  keep  the  patient  in  a  bright  sunlight. 

Medicinally,  arsenic  is  indicated.  Searcy  recommends  it  in 
the  form  of  atoxyl,  gr.  iss  doses,  once  a  week  hypodermicallyj 
increasing  to  2  grains. 

MALARIA. 

By  Wm.  Britt  Burns.^ 

Synonyms. — Malaria;  ague;  paludism;  intermittent  fever; 
paludisme  (Fr.) ;  Wechsel  fieher  {Gr.) ;  paludismo   (It.). 

Definition. — A  specific  infectious  disease,  due  to  the  invasion 
of  the  blood  of  several  species  of  the  hemosporidia  of  the  genus 
Plasmodium  malarias.  The  disease  manifests  itself,  according 
to  the  species  of  infecting  parasite,  in  three  types,  which  are 
distinguished  in  common  by  the  occurrence  of  periodical,  inter- 
mittent or  subintrant  febrile  paroxysms. 

Historical  Note. — Contemporaneous  writers  of  ancient  times 
chronicle  the  fact  that  malaria  then  existed.  We  learn  from 
the  writings  of  A.  Groff  that  malaria  was  well  known  to  the 
early  Egyptians.  The  word  "Aat"  occurring  as  an  inscription 
on  the  temple  at  Denderah,  is  said  to  indicate  the  annual  recur- 
ring epidemic.  Our  knowledge  of  malaria  has  been  moulded 
for  us  by  the  a<iute  observations  and  fairly  accurate  accounts 
of  the  disease  by  Hippocrates,  Galen  and  Celsus,  before  the  dis- 
covery of  Peruvian  bark  (Cinchona),  in  1640. 


^  Dr.  Burns  while  a  resident  near  the  swamps  of  Arkansas  did  a  large  amount 
of  original  work  upon  the  subject  of  malaria,  before  taking  up,  in  recent  years,  a 
general  surgical  practice  in  Memphis,  Tenn.  At  the  time  the  work  of  Ross,  Grassi 
and  l>astianelli  was  in  progress.  Dr.  Burns  checked  it  in  his  observations.  Dr.  J. 
B.  McElroy,  of  Memphis,  has  read  the  manuscript  and  corrected  the  proof  of  this 
chapter. 


GENERAL   DISEASES.  347 

With  this  period  are  associated  the  names  and  work  of 
Sydenham,  Torti  and  Morton.  Torti  and  Morton  divided  the 
'^essential  fevers"  into  two  classes,  namely,  those  that  were  cur- 
able by  treatment  with  cinchona  bark  and  those  in  which  it  had 
no  effect.  Lancisi  was  the  first  to  conjecture  a  relationship 
between  malaria  and  the  telluric,  meteorologic  and  climatic  con- 
ditions; also  to  notice  the  very  dark  color  of  the  liver  at  necrop- 
sies in  fatal  cases  of  malaria.  In  the  eighteenth  century  de 
Haen  noticed  the  rise  of  temperature  during  the  chill. 

During  the  latter  part  of  the  eighteenth  century  rapid  coloni- 
zation all  over  the  world  made  the  differentiation  of  malaria 
from  other  endemic  tropical  and  subtropical  diseases  difficult 
indeed.  The  separation  was  satisfactorily  accomplished  in  the 
nineteenth  century.  So  that  this  epoch  ends  with  the  discovery 
of  the  malarial  parasite  by  Laveran  in  1880. 

The  characteristic  bodies  having  been  found,  the  study  of  the 
mode  of  infection  began  to  be  hypothesized.  Nott  of  Mobile, 
Ala.,  in  1848  published  a  paper  on  yellow  fever,  and  in  touch- 
ing on  malaria  wrote  as  if  the  mosquito  theory  had  already  been 
advanced.  King  in  "Washington  in  1883  collected  evidence; 
Laveran  in  1891 ;  Bignami  in  1896  suggested  that  the  mosquito 
might  be  the  infecting  agent.  Koch  claims  to  have  thought  of 
it  in  1883-4.  But  Patrick  Manson  in  1894,  was  the  first  to 
offer  argument  in  support  of  the  ''conjecture"  as  he  called  it. 

The  third  and  grand  epoch  in  the  advances  of  our  knowledge 
was  opened  by  Surgeon-Major  Ronald  Ross  of  the  Indian 
Medical  Service,  who  in  1895  began  to  elucidate  and  prove  ]\Ian- 
son's  theory,  and  in  September,  1897,  after  examining  a  thou- 
sand mosquitoes  for  both  avian  and  human  malaria.  The  Ital- 
ians, Grassi,  Bignami  and  Bastianelli,  in  1898,  confirmed  the 
work  of  Ross. 

Etiology. — The  Plasmodium  malariae,  the  infectious  agent,  is 
introduced  into  the  human  body,  by  the  bite  of  mosquitoes  of 
a  certain  variety,  namely,  anophelinae,  which  have  themselves 
been  infected  by  feeding  upon  individuals,  whose  blood  con- 
tained sexual  forms  of  the  malarial  parasites. 

The  endogenous  cycle  or  schizogony  in  a  new  infection  be- 
gins  with    the    sporozoites,    penetrate    healthy    red    corpuscles, 


348 


THE   DISEASES   OP    CHILDREN. 


Fig.    64. — Anopheles   Crucians.     Female 
mosquito,  greatly  enlarged. 


Fig.    65. — Anopheles  punctipennis.     Fe- 
male mosquito,   greatly  enlarged. 


Fig.     66. — Anopheles     quadrimaculatus. 
Female  mosquito,   greatly   enlarged. 


Fig.    67. — Anopheles    mosquito    at    rest.        Fig.     68. — Common    mosquito     at    rest. 


Note. — Figs.   64,   65,   66,   67,   68  from  article  by  Dr.   S.   P.   Lathrop,   New  York 
City,  published  in  June,    1913,   Medical  Herald. 


GENERAL  DISEASES.  349 

barring  phagocj'tosis,  becoming  trophozoites  or  ring  forms,  and 
later  schizonts.  These  bodies  feed  upon  the  red  cells,  con- 
verting their  hemoglobin  into  melanin,  reaching  their  full 
growth ;  the  segmentation  stage,  or  ' '  roset ' '  form,  they  divide  by 
schizogony  into  a  number  of  spores  or  merozoites.  The  rem- 
nant of  the  red  cell,  with  its  contained  pigment,  having  dis- 
integrated, the  merozoites  are  set  free  to  attack  other  uninfected 
and  occasionally  infected  red  cells.  The  asexual  or  schizogonic 
cycle  is  completed. 

When  the  parasites  are  first  introduced  into  the  blood,  their 
numbers  are  relatively  small,  hence  for  a  certain  length  of  time 
no  symptoms  are  produced  upon  the  host,  the  so-called  incuba- 
tion stage,  measuring  from  6  to  12  days.  During  this,  it  is 
said,  the  schizogonic  stage  only  is  reached.  About  this  time 
the  reaction  of  the  patient,  as  in  the  production  of  fever,  appears 
to  stimulate  the  merozoites  to  development  into  the  sexual  forms, 
namely,  the  male  or  microgametocyte,  and  the  female  or  macro- 
gametocyte.  If  the  host  is  now  bitten  by  the  proper  mosquito, 
these  sexual  forms,  with  other  forms,  are  taken  into  its  stomach, 
where  the  remnants  of  red  corpuscles  and  their  contained  pig- 
ment and  the  asexual  forms  of  parasites  are  digested,  etc.  The 
male  cells  put  out  flagella  (microgamete),  which,  after  a 
decided  hammering  motion,  are  thrown  off,  and  finding 
the  female  cells  (macrbgamete)  penetrate  and  fertilize  them. 
The  conjugation  stage  is  called  the  zygote  and  the  next  step  the 
ookinete.  When  this  is  accomplished,  the  ookinete  pushes  its  way 
into  the  wall  of  the  mosquito's  stomach  and  begins  its  growth. 
The  oocyst  is  formed ;  inside  of  which  is  developed,  first,  spor- 
oblasts;  second,  sporozoites.  The  oocyst  is  seen  to  be,  in  size, 
in  proportion  to  the  length  of  time  between  the  feeding  and 
death  of  the  insect,  namely :  They  may  reach  a  greater  size, 
according  to  Stephens. 

-7  microns  after  two  days 

17  microns  after  four  days 

19  microns  after  five  days 

25  microns  after  seven  days   (Ross) 

The  oocyst  having  reached  its  full  development  ruptures,  and 
a  large  number  of  curved,  thread-like  bodies,  sporozoites,  escape 


350  THE   DISEASES   OF    CHILDREN. 

into  the  surrounding  serum.  These  bodies  are  now  ready  and 
fit  to  be  introduced  into  the  host.  On  staining,  the  sporozoites 
contain,  centrally  located,  one  or  two  small  masses  of  nuclear 
matter,  and  measure  14  microns  in  length,  tapering  at  either, 
end.  In  the  unstained,  fresh  specimens,  they  exhibit  a  decided 
writhing  motion. 

Quartan  Parasite. — The  quartan  parasite  is  smaller  than  the 
enveloping  red  cell,  when  its  segmentation  stage  is  reached;  it 
causes  the  red  cell  to  shrink  and  usually  becomes  darker  in  color. 
Its  full  development  is  accomplished  in  72  hours. 

Beginning  with  the  sporozoite  or  ring  form  (hyalin  body), 
as  a  pale,  refractory  spot  in  the  substance  of  the  red  corpuscle, 
usually  eccentrically,  about  1/10  the  size  of  the  containing  cell; 
it  feeds  upon  the  hemoglobin,  converting  this  into  pigment  and 
proper  tissue.  The  pigment  of  the  quartan  parasite  is  char- 
acteristic, in  that  it  is  darker  and  in  larger  blocks  or  grains 
and  lazier,  than  the  pigment  seen  in  the  other  varieties  of 
Plasmodia.  Between  the  hyaline  stage  and  the  segmentation 
stage,  the  different  forms  are  merely  larger  parasites,  with  more 
and  more  pigment.  The  melanaemia  of  malaria  is  one  of  its 
most  characteristic  features.  Two  varieties  of  pigment  occur, 
namely,  melanin  and  hemosiderin;  the  second  is  found  in  the 
internal  organs  and  gives  the  reaction  to  iron ;  the  first  is  found 
in  the  circulating  blood  everywhere.  The  quartan  divides  into 
from  6  to  10  spores  or  merozoites. 

The  Benign  Tertian  Parasite.  Plasmodium  vivax. — The 
growth  of  the  benign  tertian  parasite  is  exactly  similar  to  that  ob- 
served in  the  growth  of  the  quartan;  it  is,  however,  very  much 
more  rapidly  motile,  the  pigment  is  finer  and  keeps  up  a  dancing 
motion,  almost  continuously.  The  containing  red  cell  begins 
to  sw^ell  early,  and  it  becomes  paler  in  color.  The  full-grown 
pigment  bodies  (schizonts)  may,  by  the  inexperienced,  be  taken 
for  a  pigmented  or  a  granular  leucocyte  in  the  fresh  blood. 
The  segmenting  body,  both  of  the  tertian  and  quartan,  have  the 
appearance  of  the  daisy  or  marguerite.  When  the  cell  ruptures 
the  remnant  of  the  cell  and  its  contained  pigment  are  carried 
to  the  spleen.  Segmentation  occurs  at  the  end  of  48  hours, 
setting  free  18  to  20  spores   (merozoites). 


.•'V 


7  rv-  ^    V5^  ^ 


Life-CycIvE  of  Plasmodium  Vivax. 

(AFTER  GRASSI  AND  SCHAUDINX.) 

The  human  i^ycle  is  above  the  transverse  line,  some  rearranged  by  Kissalt  and  Hartmann. 
The  cycle  in  the  mosquito  is  beneath.  1  to  7,  Schizogony:  1,  sporozoite:  2,  entrance  of  sporozoite; 
f!  and  4,  growth  of  the  schizont:  5  and  6,  nuclear  division  of  the  schizont;  7,  formation  of  the  mero- 
zoites:  8,  merozoites:  9a  to  12a,  growth  of  the  macrogametocyte;  9b  to  12b,  growth  of  micro- 
gametoeyte:  13c  to  17c,  parthenogenesis  of  the  macrogametocyte;  13a  and  14a,  maturation  of 
macrogamete:  13b  and  14b.  growth  of  the  microgamete:  15b,  microgamete:  16,  fructification;  17, 
Ookinete:  18  to  20,  entrance  of  the  Ookinete  into  the  stomach  wall  of  the  mos(iuito:  20  to  2.5, 
sporogony:  22  and  23,  nuclear  multiplication  in  the  sporont;  24  and  2.5,  formation  of  the  sporozoites; 
2f),  passage  of  the  sporozoites  to  the  salivary  gland;  27,  salivary  gland  of  the  mos<iuito  with 
sporozoites  (Magn.  1  to  17c,  1200  to  1:  ]H  to  27c,  600  to  1.)     Park:  Pathogenic  Bacteria  and  Protozoa. 


GENERAL   DISEASES.  351 

The  Estivoautumnal  Parasite  {Laverania  Malarm). — The 
young  forms  of  this  variety  of  malarial  parasite  are  somewhat 
smaller  than  either  of  the  other  forms;  not  so  motile  as  the 
tertian,  and  does  not  show  the  amount  of  pigment  of  either. 
The  full-grown  bodies  are  about  the  size  of  the  red  corpuscle; 
at  this  stage  they  show  several  grains  of  rather  coarse,  black 
pigment.  The  segmenting  body  is  divided  rather  symmetrically 
into  from  8  to  25  merozoites.  The  sexual  forms,  ovoids  and 
crescents  (gametocytes),  develop  after  a  few  days  of  the  infec- 
tion. The  staining  reaction  of  all  of  these  forms  is  quite 
characteristic : 

In  a  suitably  stained  preparation  (using  a  chromatin  dye)  tlie  young 
parasite  appears  to  be  a  disk,  consisting  of  a  central,  pale,  unstained  area, 
known  as  the  achromatic  zone,  and  of  a  basic  (blue)  periphery,  the  body, 
including  a  metachromatically  stained,  rounded,  compact  (red),  chromatin 
mass,  the  nucleus,  which  tends  to  give  the  parasite  the  form  of  a  signet 
ring.  Later  stages  up  to  a  certain  number  of  hours,  show  simple  changes  in 
size  and  outline  of  the  body.  The  nucleus  then  divides  by  simple  mitosis. 
Later  it  breaks  up  by  amitotic  division  into  an  increasing  number  of 
angular  pieces.  By  the  time  that  chromatin  division  is  completed,  the 
angular  chromatin  masses  will  have  assumed  a  rounded  form,  and  will  be 
seen  to  exhibit  ultimately  the  same  strong  affinity  for  certain  dyes  which 
is  seen  in  the  compact  chromatin  body  of  the  young  ring-like  form.^ 

When  the  parasite  undergoes  division  the  merozoites  show, 
on  staining,  a  chromatin  mass  with  each  achromatic  body.  The 
best  stain  is,  probably,  Leishman's  or  Wright's  modification  of 
Romano wsky's  stain  (eosinate  of  oxidized  methylene-blue), 
which  is  made  as  follows: 

Leishman's  Modification  of  Romanowsky's  Method.' 

Leishman's  method  gives  good  results  for  general  blood  work, 
fixing  at  the  same  time  as  it  stains.  It  has  also  the  advantage 
that  it  stains  the  red  blood  cori)useles  infected  by  the  malarial 
parasite  in  a  special  manner. 

Solution  A.  One  per  cent  medicinal  methylene-blue  (Grub- 
ler)  in  distilled  water;  add  0.5  per  cent  Na^COs  until  alkaline. 


iPark:    Pathogenic   Bacteria   and   Protozoa. 

2  British    Medical    Journal:    Methods    of    Morbid    Histology    and    Clinical    Pathology, 
Walker  Hall  and  Herxheimer, 


352  THE  DISEASES   OF    CHILDREN, 

Heat  to  65°  C.  in  paraffin  oven  for  12  hours;  allow  to  stand 
at  room  temperature  10  days  before  use. 

Solution  B.  Eosin  (extra  B,  A.  Grubler),  1  gm. ;  distilled 
water,  1000  cc. 

Mix  equal  volumes  of  A  and  B  in  a  large  open  vessel ;  allow 
to  stand  for  6  to  12  hours,  stirring  occasionally.  Collect  the 
precipitate  on  a  filter,  wash  with  distilled  water  until  the  wash- 
ings become  almost  colorless,  dry  and  powder  the  residue. 
(Grubler  now  makes  this  dye,  and  it  may  be  also  obtained  in 
"soloid"  form  from  Burroughs,  Welcome  &  Co.) 

To  Prepare  Hie  Stain. — Dried  pi:ecipitate  (green,  metallic 
lustre),  0.3  gm. ;  pure  methyl  alcohol  (Merck  "for  analysis"), 
200  ec. 

The  solution  is  of  a  dark-blue  color,  show^s  a  greenish  iri- 
descence by  reflected  light,  and  when  kept  in  stoppered  glass 
bottles  does  not  deteriorate. 

Staining. 

1.  Prepare  a  thin  film.     Dry  in  the  air. 

2.  Stain  with  4  drops  of  dye  for  30  seconds. 

3.  Add  to  the  alcoholic  stain  6  or  8  drops  of  distilled  water, 
and  allow  it  to  mix  with  the  dye  (by  rotating  the  forceps). 

4.  Allow  the  film  to  stain  for  5  minutes  (if  film  is  very  thick, 
10  minutes). 

5.  Wash  the  stain  aw'ay  with  distilled  water.  Allow  a  few 
drops  of  water  to  rest  upon  the  film  for  1  minute. 

6.  Dry  in  air  or  with  blotting  paper.     Mount  in  xylol  balsam. 
Red, — Neutrophile,  or  fine  eosinophile  granules. 

Ruhy  Red. — Nuclei  of  polymorphonuclear  and  mononuclear 
leucocytes. 

Pink. — Red  blood  corpuscles.     Eosinophile  granules. 

Violet  to  Purple. — Basophile  granules. 

Pale  Blue. — Extra  nuclear  protoplasm  of  leucocytes  and 
lymphocytes. 

Blue. — Plasmodium  malaria.     Bacteria. 

If  the  red  corpuscles  appear  bluish  instead  of  pink,  the  pink 
color  may  be  restored  by  washing  the  film  in  1  .-1500  acetic 
acid  solution.  Heat  may  not  be  used  to  dry  the  film,  as  it 
breaks  up  the  stain  and  decolorizes  the  chromatin. 


GENERAL   DISEASES.  353 

If  a  granular  deposit  is  deposited  on  the  films,  remove  it  by 
washing  quickly  in  absolute  alcohol,  the  film,  after  a  few  sec- 
onds, being  plunged  into  distilled  water  to  stop  the  decolorizing 
effect  of  the  alcohol. 

For  Schuifner's  and  Maurer's  "dots"  stain  with  the  mixture 
of  stain  and  water  for  1  hour,  placing  the  preparation  under 
a  watch  glass  or  the  lid  of  a  petri  dish  to  check  evaporation. 

Stain  for  10  minutes  or  longer;  wash  in  water.  Dry  without 
using  heat. 

The  most  common  errors  among  beginners,  in  stained  speci- 
mens, is  the  mistaking  of  a  fragment  of  a  leucocyte  lodged 
upon  a  red  cell  for  one  of  the  ring  forms  of  parasite. 

Blood  Picture. — In  the  human  blood  there  are  only  the  nor- 
mal elements  with  which  to  confuse  malarial  parasites;  these 
are,  erythrocytes,  leucocytes,  platelets,  products  of  coagulation 
and  technique.  In  the  fresh  specimen,  shrunken,  spiculated, 
crenated  red  cells  and  shadow  corpuscles  are  often  mistaken 
for  parasites.  Vacuoles  in  the  red  corpuscles,  and  fragments, 
often  round  in  shape,  adherent  to  the  red  cells,  are  frequently 
confused  with  the  young  hyaline  or  ring  forms ;  thread-like 
debris  for  fiagella.  Large  pigmented  leucocytes  may  be  con- 
fused with  the  full-grown  pigment  bodies  of  the  benign  tertian. 

Heredity. — The  question  of  heredity  has  been  little  considered. 
Duchek  found  a  large  pigmented  spleen  and  pigment  in  the 
portal  vein  in  a  child  dying  three  hours  after  birth,  born  of  a 
malarious  mother.  Since  the  discovery  of  the  Plasmodium,  Bein, 
Bouzian  and  Peters  found  the  malarial  organism  in  the  blood 
of  new-born  infants;  probably,  however,  such  infants  had  had 
opportunity  to  become  infected  since  birth.  By  analogy  there 
seems  to  be  no  good  reason  to  controvert  the  idea  of  transmission 
of  the  malarial  parasite  through  the  placental  circulation. 
Germs  proper  to  diseases  such  as  charbon,  chicken  cholera  and 
septicemia,  etc.,  have  been  demonstrated  in  the  embryos  of  ani- 
mals dead  of  these  respective  diseases.  The  typhoid  bacillus  was 
found  in  the  lungs,  spleen,  kidneys  and  mesenteric  glands  of 
a  child  five  days  old,  the  offspring  of  a  mother  who  had  con- 
tracted typhoid  fever  in  the  eighth  month  of  pregnancy.  Trans- 
mission of  syphilis  is  assumed  as  obtaining  through  the  pla- 


354  THE   DISEASES   OF    CHILDREN. 

cental  circulation.  Bignami,  Bastianelli,  Caccini,  Thayer  and 
Schaudinn  have  examined  the  blood  of  infants  born  of  malarious 
mothers  and  placental  blood,  and  they  do  not  believe  the  trans- 
mission through  the  placental  blood.  Though  necropsies  of 
several  fetuses  from  infected  mothers  have  negatived  the  pre- 
sumption of  hereditary  malaria,  a  positive  conclusion  is  still  not 
a  violent  one. 

Susceptibility. — The  great  liability  of  the  child  to  get 
malaria  becomes  a  question  of  easy  solution  when  mosquito  in- 
oculation is  accepted.  The  child  is  the  first  to  be  put  to  bed 
and  is  the  first  to  sleep ;  the  arms  and  legs  and  maybe  half 
the  body  are  bare.  The  skin  is  delicate  and  tender,  and  as  com- 
pared with  the  adult,  clean,  the  exhalations  from  this  organ 
lack  the  odor  emanating  from  the  adult.  The  adult  does  not 
retire  until  the  mosquitoes  have  filled  themselves  from  the  blood 
of  their  children;  they  are  better  protected  by  clothing,  shoes, 
etc.,  and  they  are  better  able  to  avoid  the  bites  of  these  insects 
than  the  infant  or  small  child. 

After  an  entrance  into  the  blood  current,  the  susceptibility 
is  still  greater  in  the  infant.  The  corpuscles  upon  which  the 
Plasmodia  feed  offer  less  resistance;  more  of  these  bodies  are 
destroyed,  comparatively,  at  each  paroxj'sm,  than  in  the  adult; 
consequently  more  toxins  are  liberated. 

Pathology. — The  benign  forms  of  malaria  do  not  produce 
many  fatalities,  and  it  is  the  pernicious  or  malignant  type  that 
supply  our  necropsies.  The  characteristic  chocolate  and  slate 
color  of  some  of  the  tissues  and  organs  of  the  body,  produced 
by  deposition  of  the  peculiar  malarial  pigment,  is  found  in  the 
subacute  and  chronic  cases.  Accumulations  of  malarial  pig- 
ment, dead  parasites,  debris  and  pavementing  of  infected  red 
cells  occur  in  the  vessels  of  the  hrain,  stomach,  lirrr.  spleen, 
kidneys  and  other  organs,  producing  actual  thrombi  and  necro- 
biotic  areas  in  some  of  these  organs.  When  it  is  considered  that 
one-sixth  or  even  one-third  of  all  the  red  corpuscles  in  the  body 
may  be  destroyed  by  one  single,  pernicious  paroxysm,  it  will 
be  understood  that  the  above-named  organs  may  become  pro- 
foundly affected. 

Liver. — The  liver  cells  are  thinned;  the  capillaries  are  dilated 


GENERAL  DISEASES.  355 

and  replaced  by  fat  drops;  a  great  polycholia  is  denoted  by  the 
filling  of  the  gall  bladder;  injection  of  the  bile  capillaries  to 
their  finest  rootlets.  Necrobiotic  changes  occupying  rather  ex- 
tensive areas  are  seen.  The  vessels  are  filled  with  pigmented 
leucocytes,  dead  parasites,  remnants  and  debris,  and  blocks  of 
yellowish-black  pigment.  Kupfer's  cells  and  certain  endo- 
thelial cells  undergo  multiplication  by  karyokinesis.  This 
hepatic  tumor  has  a  blackish,  leaden  appearance,  and  is  soft  on 
section.  More  or  less  perilobular  fibrosis  obtains  where  there 
have  been  repeated  infections.  There  is  objection,  however,  to 
the  idea  of  portal  cirrhosis  from  malaria  alone. 

Spleen. — The  splenic  tumor  may  be  merely  palpable  below 
the  costal  margins,  or  it  may  reach  below  the  navel  and  to  the 
anterior  superior  spinous  process  of  the  ilium.  Postmortem, 
the  surface  of  the  spleen  is  dark,  sometimes  black ;  on  section 
the  gland  tissue  is  also  found  to  be  dark ;  the  parenchyma  of  the 
organ  is  much  softened;  the  tarry  pulp  may  be  washed  away 
with  quite  a  gentle  stream  of  water.  The  pigment  of  malaria 
is  here  found  within  the  endothelium  of  the  arterioles  and  capil- 
laries in  minute  grains,  often  in  actual  blocks;  we  find  aggrega- 
tions of  pigmented  leucocytes,  dead  and  breaking-down  para- 
sites forming  thrombi  and  actually  occluding  the  vessels.  The 
spleen  and  bone  marrow  have  the  distinction  over  all  other 
organs  of  containing  pigment  in  the  cells  of  the  parenchyma  out- 
side and  away  from  the  blood  vessels.  In  these  latter  organs 
pigment  is  contained  in  ordinary  leucocj'tes,  but  in  the  splenic 
vein  this  subtance  is  included,  not  only  in  leucocytes,  but  also 
in  certain  large  white  cells  identical  with  those  occurring  in 
the  spleen,  and  evidently  of  splenic  origin. 

Kidneys. — The  renal  changes  are  not  as  severe  as  has  been 
supposed,  especially  in  the  milder  forms  of  malaria.  Grossly, 
thej^  are  slightly  enlarged  and  pale  in  color.  Small  evidence  of 
pigmentation.  Microscopically,  the  glomeruli  and  the  inter- 
lobular vessels  are  seen  to  contain  infected  red  cells  and  pig- 
mented leucocj'tes.  In  the  pernicious  forms,  and  especially  the 
hemoglobinuric  form,  the  kidneys  in  the  early  stage  of  the 
disease  are  enlarged  and  congested;  the  tubules  are  blocked 
with  hemoglobin  infarcts;  the  cells  are  loaded  with  yellow  pig- 


356  THE   DISEASES   OF    CHILDREN. 

ment  grains,  and  the  capillaries  with  black  malarial  pigment. 
The  appearances  are  then  those  of  the  large,  white  kidney.  The 
severest  cases  of  nephritis  of  malarial  origin  are  found  in 
hemoglobinuria.  The  capillaries  in  the  medulla  and  papillae 
are  often  filled  with  infected  cells  and  parasites;  while  the 
tubules  are  filled  with  casts,  in  which  are,  sometimes,  entangled 
infected  red  cells,  parasites  and  pigmented  leucocytes.  Ewing 
reports  a  case  of  acute  hemorrhagic  nephritis  of  malarial  origin. 

lliG  Bone  Marrow. — ^^INIany  sexual  and  pigmented  forms  and 
free  pigment,  pigmented  leucocytes  and  macrophages  harbor  in 
the  bone  marrow.  The  small  capillaries  here  are  frequently 
choked. 

Respiratory  Organs. — The  bronehitic  and  bronchopneumonia 
manifestations  are  seldom  seen  in  the  very  young.  I  have, 
however,  seen  several  cases,  in  adults,  where  there  was  spitting 
of  blood  and  other  signs  of  pneumonia,  accompanying  the  par- 
oxysm, and  which  cleared  up  with  the  administration  of  quinine 
and  the  subsidence  of  the  fever. 

Symptoms  and  Clinical  Outline. — It  is  the  duty  of  the  physi- 
cian to  carefully  instil  into  the  minds  of  the  parents  the  grave  im- 
portance of  noting  the  little  indispositions,  of  whatever  nature, 
of  the  infant  in  a  malarial  region.  A  child  does  not  cry  and 
fret,  does  not  refuse  to  nurse  or  eat,  does  not  get  nauseated  or 
become  restless  at  night,  will  not  stop  play  for  nothing.  The 
mothers  in  the  bottoms  soon  learn  this.  Eternal  vigilance  here 
is  the  price  of  liberty. 

There  is  no  disease  which  may  reach  alarming  proportions  in 
children  so  stealthily  as  that  of  malaria — yet  so  surely  raises 
the  danger  signal,  if  one  has  been  observant. 

We  are  to  look  for  fretfulness,  nausea,  vomiting,  stomachache, 
diarrhea,  dysentery,  epistaxis,  excessive  or  scant  urinary  flow, 
drowsiness,  fetid  breath,  coated  tongue,  headache,  backache, 
feverishness  and  fever,  etc.  Any  one  or  most  of  these  symptoms 
may  be  present  in  a  mild  degree,  one  day,  slightly  more  severe 
the  next  day — the  third  day  (or  even  the  second  day)  the  blood 
is  supersaturated  with  toxins,  the  nervous  system  is  over- 
whelmed, pupillary  manifestations  appear — one  pupil  dilated, 
the  other  contracted,  the  extremities  are  in  clonic  convulsions. 


GENERAL   DISEASES.  357 

the  jaws  are  clinched,  unconsciousness  comes  apace.  This  is  the 
eclamptic  form,  or  the  condition  generally  known  as  "con- 
gestion," from  which  so  many  babies  die  in  the  river  bottoms 
of  the  South.  Indeed,  there  is  a  general  congestion,  the  most 
prominent  symptoms  may  direct  in  one  instance  to  the  brain, 
in  another  to  the  liver,  and  still  another  to  the  stomach.  The 
convulsions  may  be  reflex  in  their  nature,  the  point  of  irrita- 
tion which  predetermines  the  flow  of  blood  to  a  given  organ 
or  part  being  large  accumulations  of  malarial  pigment,  dead 
parasites  and  debris,  often  occluding  large  vessels  and  lymph 
spaces.  Often  one  sees  families  who  have  had  born  to  them 
five,  six  and  even  ten  children,  and  only  one,  two  or  three  of 
these  live  to  cheer  and  brighten  their  homes,  and  in  each  in- 
stance one  is  told  that  all  of  these  little  ones  perished  with  so- 
called  malarial  congestion. 

However,  not  all  children  suffer  with  acute  malaria ;  a  good 
percentage  of  them  have  chronic  malaria,  cachexia ;  one  or  two 
mild  chills;  quinine  administered  in  mild  doses  just  sufficient 
to  prevent  the  next  paroxysm,  then  given  indifferently  or  not 
at  all.  The  child  goes  on  with  considerable  blood  destruction, 
accumulating  pigment,  bile  and  malaria,  their  little  skins  take 
on  a  bronzed  appearance,  thickened  and  dry  as  parchment ;  soon 
the  spleen  fills  up  and  may  be  felt  from  2  inches  below  the  ribs 
to  as  low  down  as  the  iliac  fossa,  sometimes  reaching  across  to 
the  opposite  side ;  its  pressure  upward  on  the  diaphragm,  with 
the  -pain  which  is  often  centerecl  in  the  upper  part  of  the  organ 
similates,  and  the  parents  are  often  apprehensive  of  pneumonia. 
The  liver  is  more  or  less  to  be  felt  below  the  costal  margins. 
Sometimes  there  are  black,  tarry  stools.  But  more  often  these 
are  clay  colored.  There  may  be  constipation,  the  rule,  how- 
ever, seems  to  tend  towards  a  looseness  of  the  bowels,  the  color 
of  the  stools  in  this  latter  condition  is  that  well  known  of  "milk 
gravy."  The  urine  is  scant  and  scalding,  highly  colored  and 
heavily  loaded  with  solids;  occasionally  there  is  a  flow  of  clear 
(water  colored)  urine.  This  may  be  regarded  as  a  manifesta- 
tion of  active  malaria,  and  generally  presages  a  paroxysm,  how- 
ever mild  it  may  be,  followed  by  only  a  little  back  or  leg  pain, 
the  Plasmodia  may  be   sought   in   the   peripheral  blood.     The 


358 


THE   DISEASES   OF    CHILDREN, 


tongue  is  large  and  flabby,  indented  by  the  teeth,  with  a  whitish 
cast;  this,  as  are  also  the  gums,  is  pale,  anemic. 

Moncorvo  believes  that  infants  and  children  so  infected  are 
physically,  mentally  and  morally  deteriorated.  He  places 
malaria  beside  syphilis  and  tuberculosis,  a  retarder  of  physical 
growth.  Every  malariologist  will  attest  that  in  the  tropics  and 
subtropics  in  the  treatment  of  any  disease,  he  has  a  malarial 


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Fig.    69. — Malarial    hemoglobinuria. 

base  to  work  upon,  even  in  wounds  which  confine  to  the  bed  or 
room  malaria  is  precipitated.  My  experience  fully  accords  with 
that  of  Moncorvo.  It  requires  no  stretch  of  the  imagination  to 
say  Avhat  three  or  four  generations  of  these  little  bronze  fellows 
wdll  bring.  It  becomes  (piite  a  social  problem,  when  our  most 
fertile  lands  are  so  poorly  habitable  on  account  of  this  infection. 
The  fatality,  according  to  L.  Colin,  of  pernicious  fevers,  in 
an  ascending  scale  is,  icterus,  comatose,  delirious  cardialgic, 
algid  and  syncopal.  As  previously  stated,  the  benign  forms  of 
malaria  do  not  produce  many  deaths,  and  are  therefore  easily 
amenable  to  treatment. 


GENERAL   DISEASES.  359 

The  hemoglohinuric  form,  upon  which  a  great  deal  has  been 
written,  is,  probably,  only  one  of  the  very  grave  manifestations 
of  pernicious  malaria;  the  discussion  of  which  could  not  be 
permitted  by  the  space  allotted  here. 

What  is  the  therapy  of  malaria?  Every  one  knows  how  to 
treat  chills  and  fever.  Alas!  it  is  that  character  of  knowledge, 
sometimes,  of  which  it  is  said :  "A  little  knowledge  is  a  danger- 
ous thing." 

Prophylaxis. — The  preventive  steps  and  safeguards  may  be 
summed  up  in  the  following  paragraphs: 

1st.  Every  effort  should  be  made  to  banish  from  the  blood 
all  Plasmodia.  Especially  should  the  blood  of  infants  be  made 
malaria  free,  because  anopheles  prefer  to  attack  infants  on 
account  of  a  delicate  skin.  This  may  be  accomplished  by  the 
proper  and  timely  administration  of  quinin. 

2d.  All  dwellings  should  be  disinfected  of  mosquitoes, 
screened  with  close-wire  netting,  and  extra  precaution  should 
be  taken  of  placing  close-gauze  netting  over  each  bed,  and  tuck- 
ing it  in  at  the  bottom.  These  bars  should  be  inspected  with  a 
good  light,  before  retiring  at  night,  to  guard  against  infected 
anopheles,  having  stolen  in  during  the  day  or  left  in  from  the 
previous  night. 

3d.  All  trees  and  bushes  should  be  cleared  away  for  a  large 
area  around  each  dwelling,  weeds  and  grass  should  be  mowed 
closely  once  a  week.  Puddles  and  pools  should  be  filled  up,  or 
if  too  large  covered  with  petroleum. 

Mosquitoes  cannot  live  in  the  summer  sun,  nor  propagate 
without  water. 

4th.  Patients  with  malarial  parasites  should  be  isolated  and 
carefully  covered  ^vith  netting  so  that  anopheles  may  not  feed 
upon  such  patients  and,  becoming  infected,  inoculate  other  per- 
sons. Blood  examinations  should  be  made  in  all  fever  cases. 
The  following  is  a  report  of  a  case  of  hemoglobinuria : 

This  patient  had  a  chill  December  17.  Quinin,  in  No.  2  capsules,  was 
administered  every  four  hours  until  hemoglobinuria  came  on. 

December  19.  At  11.30  a.  m.  the  patient  was  comparatively  comfortable, 
and  slightly  drowsy.  The  urine  was  dark.  A  smear  of  blood  was  taken 
and  while  examining  it  I  was  hurriedly  summoned.     I  found  the  urine  the 


360  THE  DISEASES  OP   CHILDREN. 

color  of  coffee.  Both  this  and  the  first  specimen  responded  to  the  guaiac- 
tiirpentin  test. 

The  first  blood  showed  plasmodia.  A  second  smear,  taken  after  the  urine 
colored  up,  showed  plasmodia,  estivoautumnal  parasites  in  all  stages  of 
development,  moderate  poikilocytosis,  a  number  of  lymphocytes,  leucocytes 
greatly  increased,  polymorphonuclear  and  mononuclear  phagocytosis. 

The  lips  and  gums  were  pale,  also  the  tongue,  which  is  large  and  flabby, 
with  a  thick,  white  coat,  and  a  tinge  of  brown  over  the  back  part.  Icterus 
notably  mild. 

At  1.30  p.  m.  calomel,  gr.  x,  and  turpentin,  gtt.  xx — turpentin  in  a  beaten 
egg — ^were  administered,  to  be  respectively,  until  the  urine  cleared  up. 
Quinin  dihydrochlorate,  gr.  viiss,  hypodermatically,  was  given  at  1.30,  5 
and  10  p.  m.,  adding  strychnin,  gr.  1/120,  to  each  injection.  At  10  p.  m. 
the  urine  was  still  black. 

December  20.  At  8  a.  m.  the  urine  was  clearing  up  nicely.  Calomel 
was  replaced  by  sodium  hyposulphite  solution,  gr.  xx,  every  two  hours. 
Beef  juice  was  ordered,  a  half  teaspoonful  every  two  hours.  Quinin  bi- 
sulphate  in  hot  solution  was  ordered,  gr.  x,  every  four  hours. 

At  5  p.  m.  the  dihydrochlorate,  gr.  viiss,  was  given  hypodermically  to 
avoid  paroxysm.  A  tepid  bath,  containing  a  little  sodium  bicarbonate  for 
a  cleanser,  followed  by  hot  whisky  and  quinin,  was  given.  Sponge  and 
normal  salt  enema  every  four  hours. 

At  11.30  a.  m.  the  urine  was  clear;  turpentin  was  discontinued,  and  at 
5  p.  m.  the  condition  was  practically  normal. 

At  10  p.  m.  the  urine  was  quite  dark. 

The  blood  contained  numerous  hyalin  bodies,  crescents  and  round  bodies; 
leucocytosis  was  marked.  There  were  a  few  lymphocytes;  phagocytosis  was 
marked,  and  there  was  an  abundance  of  pigment  and  pigmented  leucocytes. 
Quinin  dihydrochlorate,  gr.  xv,  was  given  in  solution.  This  was  vomited 
and  repeated  immediately  and  retained.  At  midnight  the  fever  was  sub- 
siding rapidh ,  and  the  urine  clearing  up  slightly.  Turpentin,  gtt.  xv,  was 
given  at  10  p.  m.,  and  repeated  in  2  drop  doses  every  two  hours  until  urine 
cleared. 

December  21.  At  8  a.  m.  the  urine  was  clear,  and  there  was  no  fever. 
The  blood  contained  free  pigment,  pigmented  leucocytes  and  debris,  also 
two  old  crescents.  Quinin  bisulph.,  gr.  v,  and  strychnin  nitrate,  gr.  1/200, 
in  solution  was  ordered.  Sodium  hyposulphite  and  beef  juice  to  be  given 
every  two  hours,  and  a  bath  and  normal  salt  solution  every  four  hours. 

December  22.  At  8  a.  m.  patient  was  put  on  tonic  and  light  diet.  It 
will  be  noted  that  at  5  p.  m.,  December  20,  quinin,  gr.  viiss.  was  given  hypo- 
dermically, yet  the  paroxysms  came  on  at  10  p.  m.,  at  which  time  quinin, 
gr.  XV,  in  solution  by  the  mouth  was  administered  and  vomited,  repeated  at 
once  and  retained,  and  cinchonism  was  prbfound.  This  may  be  evidence 
of  precipitation  of  the  alkaloid  by  the  alkaline  tissues. 

Treatment. — "When  quinin  for  any  reason  is  contraindicated 


GENERAL   DISEASES.  361 

we  are  almost  entirely  without  a  substitute ;  this  very  fortu- 
nately does  not  often  occur.  Quinin  and  the  other  cinchona 
derivatives  exert  a  specific  action  on  the  plasmodia,  and  all 
forms  of  malaria  respond  to  its  action,  if  the  case  is  seen  in 
time.  An  infant  or  child  should  not  be  allowed  to  have  a  second 
or  third  chill  even  of  the  benign  types.  Pernicious  paroxysms 
of  every  variety,  icteric,  comatose,  delirious,  algid,  eclamptic 
or  syncopal  require  heroic  treatment,  and  should  he  met 
prom,ptly  hy  large  doses  of  quinin  hypodermically. 

The  necessity  for  a  good  liver  arousement  is  here  very  urgent. 
For  the  spasms,  chloral  hydrate  or  bromide  of  potash,  either 
or  both,  may  be  used ;  it  will  be  found  that  these  will  be  often 
vomited ;  a  hot  mustard  bath  or  a  hot  normal  salt  enema  may 
be  of  value. 

For  cachexia  quinin  in  sufficient  doses  and  tonics  for  40  days 
in  connection  with  tonics.^ 

SYPHILIS;  LUES. 

Syphilis  is  a  communicable  disease,  in  infancy  either  heredi- 
tary or  acquired.  The  latter  form,  evidenced  by  the  initial 
lesion,  the  train  of  secondary  lesions,  showing  in  the  mucous 
membranes  and  skin,  and  the  tertiary  manifestations  in  the 
bones,  viscera  and  nervous  system. 

Another  phase  which  is  of  interest  to  pediatrists  is  that  form 
of  syphilis  in  infancy  termed  tarda,  which  Fournier  states  may 
"  manifest  itself  at  any  age,  from  young  adult  up  to  old  age." 

Etiology. — The  recent  investigations  which  have  conclusively 
proven  the  spirocheta  pallida  to  be  the  specific  organism  of 
syphilis  have  cleared  up  the  etiology  of  this  condition.  This 
organism  has  been  isolated  and  reproduced  on  the  chimpanzee, 
and  it  has  been  found  in  the  tissues  of  the  syphilitic  infant. 

The  question  of  transmission  of  the  syphilitic  virus  to  the 
infant  has  been  a  moot  one  in  medicine  for  vears.     Belief  in 


1  Bibliographv.  Thaver,  Allbutt  and  Rolleson,  Vol.  II.  Part  2.  Minehin,  ,411butt 
and  RoUeson.  Vol.  II,"  Part  2.  Stephens.  Allbutt  and  Rolleson.  Vol.  II,  Part  2. 
Ross,  Brit.  Med.  Jour.  Stephens,  Mannaberg,  Nothnagel,  Vol.  Malaria  and  Influ- 
enza. Deaderick  for  reprints.  Burns,  Hemoglobinuria ;  Mosquito  as  a  Definitive 
Host  in  Malaria.  Mosquito  as  a  Definitive  Host  in  Malaria — A  Further  Considera- 
tion. Some  General  Remarks  on  Mnlarai:  Malaria,  Quinin  in.  Infantile  Malaria: 
Laveran    New    Sydenham   Society,    Celli    and   Craig. 


362  THE   DISEASES   OF    CHILDREN. 

parental  infection  direct,  without  infection  of  the  mother,  gave 
rise  to  Colles'  law  in  1837,  which  was  as  follows: 

A  new-born  child  affected  with  inherited  syphilis,  even  though  it  may 
have  symptoms  in  its  mouth,  never  causes  ulceration  of  the  breast  which 
it  sucks,  if  it  be  the  mother  who  suckles  it,  although  continuing  capable 
of  infecting  a  strange  nurse. 

In  the  light  of  modern  knowledge  of  the  etiology  of  syphilis, 
we  know  this  law  to  be  untenable.  AVhile  the  mother  may  seem 
healthy,  she  has  become  infected  through  the  medium  of  the 
spermatozoa  and  ovum  and  is  latently  syphilitic,  the  syphilis 
being  so  mild  in  the  mother  as  to  escape  observation.  By 
means  of  reactions  of  Wassermann  and  Noguchi,  which  are 
typical  only  in  the  syphilitic,  it  has  been  shown  conclusively 
that  mothers  bearing  syphilitic  children  and  showing  no  lesions 
are  in  fact  syphilitic. 

Mode  of  Transmission. — The  infection  of  syphilis  may  be 
carried  to  the  embryo  in  the  following  ways:  Direct  from  the 
father,  through  the  medium  of  the  spermatozoa,  there  causing 
an  infection  of  the  mother,  which  may  or  may  not  be  recog- 
nized. The  time  of  greatest  infectious  possibility  in  the  father 
through  the  spermatozoa  is  after  the  primary  and  acute  sec- 
ondary manifestations.  The  greatest  danger  of  direct  infection 
of  the  mother  is  during  the  early  stages.  It  is,  however,  claimed 
by  some  authorities  that  the  disease  is  not  transmitted  by  means 
of  the  spermatozoa. 

If  the  father  becomes  syphilitic  after  impregnation,  infection 
of  the  fetus  will  be  through  the  placenta  from  the  mother  direct. 

The  infection  may  be  from  the  mother  direct,  the  father 
being  healthy. 

If  pregnancy  is  advanced  some  time  in  a  mother  not  syphilitic, 
and  she  contract  syphilis  later  in  pregnancy,  the  child  may  be 
born  healthy.  The  chances  of  a  healthy  child  being  born  is  in 
direct  relation  to  the  duration  of  the  pregnancy.  If  both  parents 
are  syphilitic  before  pregnancy,  the  offspring  will  be  syphilitic. 

Treatment  of  parents  after  infection  makes  possible  a  healthy 
offspring  after  such  treatment. 

A  syphilitic  woman  who  has  not  been  intelligently  treated, 


GENERAL   DISEASES.  363 

will  give  a  history  of  frequent  early  abortions  or  miscarriages 
before  midpregnancy,  or  if  progressed  to  full  term  will  give 
birth  to  a  syphilitic  child. 

Pathology. — Syphilitic  changes  in  the  placenta  are  fairly  typi- 
cal. The  villi  are  much  hypertrophied,  and  swollen  vessels,  some 
containing  thrombi,  are  in  the  affected  area.  There  is  a  fatty 
degeneration  of  the  epithelial  covering.  In  addition  to  this  the 
spirocheta3  pallida  have  been  found  in  the  sj'philitic  placenta 
though  more  often  in  the  stroma  and  on  the  villi.  The  placenta 
is  larger  than  normal.  Nathan  Larrier  and  Brideau  ^  claim 
that  spirochetes  may  be  transmitted  between  maternal  and  fetal 
structures,  and  vice  versa,  as  follows :  1st.  A  change  in  structure 
of  the  villus  and  the  passage  of  the  parasite  through  the  media- 
tion of  perivascular  infarcts  with  or  without  the  intervention 
of  leucocytes,  a  pathologic  process.  2d.  Transmission  of  the 
treponema  by  the  proliferating  cells  of  Langhans  a  physiologic 
process,  an  important  factor  because  of  the  ability  of  the  cells 
of  Langhans  to  penetrate  into  the  vascular  system  of  the 
decidua. 

The  spirocheta  may  be  found  in  many  of  the  organs  of  the 
infant,  the  liver,  lungs,  ovaries,  testes,  spleen,  and  in  the  blood. 

The  principal  changes  which  take  place  in  the  fetus  as  the 
result  of  syphilis  occur  in  the  bones,  certain  of  the  viscera,  the 
skin  and  the  lymph  nodes.  In  the  hones  there  is  an  inflamma- 
tion at  the  site  of  greatest  activity  and  growth,  or  a  deposit 
of  bony  tissue  on  the  shaft  of  the  bone.  AVhen  this  inflam- 
matory deposit  occurs  in  the  proximal  ends  of  the  phalanges  it 
is  termed  a  dactylitis.     The  long  bones  are  chiefly  affected. 

The  liver  shows  an  interstitial  change  and  usually  is  en- 
larged. There  is  a  round-cell  inflammation  in  this  organ. 
Gumma  may  be  found.  The  spleen  is  enlarged  and  also  shows 
the  same  increased  connective  tissue  as  the  liver.  The  same 
hyperplasia  of  connective  tissue  is  found  in  the  lungs  and 
Jcidneifs.  The  lymph  nodes  show  a  round-cell  infiltration  and 
enlargement. 

The  lesions  in  the  skin  may  be  of  many  kinds,  erythema,  blebs, 
bullae,  papules,  and  pustules.     The  mucous  membranes  may  show 


^Wall:  American   .Journal   of    Obstetrics,    June,    1908, 


364  THE   DISEASES   OF    CHILDREN. 

superficial  or  deep  ulceration.  These  may  be  the  typical  mucous 
patches. 

S3nnptoms. — A  syphilitic  child  may  be  prematurely  born, 
macerated  and  covered  with  characteristic  skin  lesions,  may  be 
born  apparently  healthy,  with  development  of  symptoms  shortly 
after  birth,  or  present  no  symptoms  for  weeks  or  months  after 
birth,  these  cases  being  classed  under  syphilis  tarda. 

In  the  second  class  of  cases  the  symptoms  usually  develop 
during  the  first  six  weeks,  and  may  be  classed  under  those  af- 
fecting the  skin,  mucous  membranes  and  bones. 

The  skin  will  usually  show  a  maculopapular  syphilide  upon 
the  face,  neck,  hands  and  feet,  and  especially  about  the  buttocks. 
The  first  skin  disturbance  may  be  found  about  the  anus.  This 
eruption  may  be  discrete  or  confluent.  "When  severe,  occasional 
bulls  or  blebs  may  appear,  and  if-  they  become  infected,  pustules 
appear,  w^hich  form  large  crusts  or  scabs  when  they  coalesce. 
Condylomata  appear  about  the  anus.  Blebs  and  bullae  may  be 
found  in  relatively  large  numbers  on  the  palms  of  the  hands 
and  soles  of  the  feet. 

Coincident  with  the  skin  lesion,  sometimes  antedating  it,  a 
coryza  develops,  the  snuffles,  which  is  quite  characteristic  of 
the  condition.  The  snuffles  is  often  preceded  by  an  inflamma- 
tory condition  of  the  posterior  nares  with  profuse  secretion, 
which  is  swallowed.  The  snuffles  may  be  present  at  birth.  There 
is  a  tendency  for  the  mucous  membrane  at  the  corners  of  the 
mouth  and  at  the  anal  margin  to  crack.  When  at  the  anus  es- 
pecially they  are  termed  rliagadcs.  ]Mucous  patches  appear  upon 
the  buccal  mucous  membrane  at  this  time  also. 

An  enlargement  of  the  epiphyses  quite  regularly  occurs  of 
the  long  bones  and  the  phalanges.  These  swellings  may  be  pain- 
ful and  tender.  Dactylitis  usually  forms,  and  this  may  involve 
the  metacarpal  and  metatarsal  bones  also.  Only  one  bone  may 
be  involved.  The  parietal  and  frontal  bosses  are  enlarged,  and 
immediately  behind  the  parietal  eminences  a  thinned  and 
softened  bit  of  bone  is  found,  the  typical  craniotdbes.  In  a 
lesser  number  of  cases  craniotabes  may  be  found  in  the  oc- 
cipital bone  also.     Softening  and  degeneration  of  the  bones  of 


GENERAL   DISEASES.  365 

the  nose  may  occur.  The  spleen  is  quite  regularly  enlarged 
and  easily  palpable.  It  is  usually  much  larger  than  in  other 
morbid  conditions.  The  lymph  nodes  are  very  generally  en- 
larged. Most  frequently  the  epitrochlea,  cervical,  axillary  and 
inguinal  glands  are  affected. 

The  child  quickly  develops  into  an  anemic,  run-down  condi- 
tion. Because  of  the  snuffles  its  nursing  is  interfered  with  and 
its  nutrition  is  quickly  impaired.  It  is  anemic  and  a  condi- 
tion of  athrepsia  soon  intervenes. 

In  syphilis  hereditaria  tarda,  in  which  the  symptoms  may 
develop  at  any  time  from  three  months  to  puberty,  the  triad  of 
symptoms  as  given  by  Hutchinson  are  interstitial  keratitis, 
labyrinthine  deafness  and  deformity  of  the  upper  incisor  teeth. 
Corneal  opacity  is  a  result  of  the  keratitis.  The  teeth  may  be 
peg  shaped  or  notched,  with  transverse  ridges  across  them. 

Gunimata  may  develop  at  any  place  in  the  body,  and  not  in- 
frequently they  appear  upon  the  skin.  When  in  the  brain  or 
cord,  symptoms  referable  to  these  regions  develop.  Synovitis 
is  not  infrequent. 

Diagnosis. — This  should  not  be  difficult  in  ca.ses  born  pre- 
maturely, presenting  the  skin  lesions  and  bony  changes.  Rickets 
may  present  some  symptoms  which  are  suggestive  of  syphilis, 
but  the  diagnosis  should  not  be  difficult.  Rickets  develops,  as 
a  rule,  later,  and  the  skin  symptoms  are  not  present.  The  bony 
changes  in  rickets  are  usually  symmetrical,  single  joints  being 
affected  in  syphilis.  Later  Hutchinson's  teeth  are  confirmatory 
evidences  of  syphilis.  , 

Prognosis. — The  influence  of  syphilis  upon  infant  mortality 
is  not  generally  appreciated.  Statistics  ^  show  a  fetal  mortality 
in  paternal  heredity  under  most  favorable  circumstances,  of  28 
per  cent ;  in  maternal  heredity,  of  67  per  cent,  86  per  cent 
and  71  per  cent,  according  to  different  observers,  and  in  mixed 
heredity  from  68  per  cent  to  86  per  cent.  Morrow  states  that 
one-third  of  all  children  born  syphilitic  die  before  they  reach 
the  age  of  six  months.  Syphilis  then  becomes  one  of  the  most 
severe  of  the  scourges   affecting  the   infant   population.     If   a 

1  Author's   paper:   Si/philis   Affecting  Infant   Mortality,   Journal  A.   M.   A.,    1904. 


366  THE   DISEASES   OP    CHILDREN. 

syphilitic  infant  is  breast  fed  it  has  a  better  chance  to  recover. 

Treatment. — If  a  diagnosis  is  made  of  syphilis  in  either  parent, 
every  means  should  be  used  to  prevent  conception. 

If  pregnancy  occurs,  by  a  syphilitic  father,  in  a  mother  who 
shows  no  signs  of  syphilis,  if  she  is  put  at  once  upon  an  anti- 
syphilitic  treatment,  which  is  conscientiously  carried  out  during 
gestation,  she  may  give  birth  to  a  healthy  child.  If  she  gives  a 
history  of  frequent  interruptions  of  pregnancy  before  term,  from 
syphilitic  causes,  she  may  go  to  full  term  and  give  birth  to  a 
healthy  child,  provided  active  treatment  is  undergone  during 
the  entire  pregnancy.  The  mother  should  nurse  the  child  and 
continue  treatment.  A  wet  nurse  should  not  nurse  a  syphilitic 
child. 

The  treatment  of  a  child,  the  subject  of  congenital  syphilis, 
should  be  begun  early  and  be  faithfully  carried  out.  It  should 
be  continued  until  the  symptoms  are  decidedly  improved  and 
then  discontinued  for  a  week,  then  resumed  for  a  period  of 
three  or  four  weeks.  Gradually  increase  the  interval  between 
a  course  of  treatments.  The  child  should  be  kept  under  treat- 
ment for  at  least  two  years,  better  for  three  years.  INIereury 
should  be  used  in  the  early  stages  and  can  be  given  by  1,  the 
mouth;  2,  hy  the  skin,  and  3,  siibcutaneously . 

In  all  forms  of  administration  symptoms  of  saturation  should 
be  looked  for. 

1.  By  the  mouth,  the  following  preparations  can  be  used : 
a.  Hydrargyrum  cum  creta  (gray  powder),  in  1  grain  doses, 
three  times  a  day.  The  chalk  usually  controls  the  laxative  effect 
of  the  mercury,  but  if  it  does  not  Dover's  powder,  i/4  grain,  can 
be  combined  for  its  effect.  The  dose  of  gray  powder  can  be 
increased  later,  h.  Calomel,  in  doses  of  1/30  to  1/10  of  a 
grain,  three  times  a  day.  Dover's  powder,  14  g^f^in*  inay  also 
be  used  with  this  if  it  causes  diarrhea,  c.  Bichloride  of  mer- 
cury, with  sugar  of  milk,  in  1/60  to  1/40  grain  doses,  d.  Pro- 
toiodide  of  mercury,  in  dose  of  1/15  to  1/10  grain. 

2.  By  inunction  the  following  can  be  used:  a.  Ung.  hydrar- 
gyri  with  equal  parts  of  lanolin,  a  piece  the  size  of  the  end 
of  the  little  finger  being  rubbed  twice  daily,  or  about  5  grains 
of  the  mercury  into  the  flexures  of  the  body,  alternately.     &. 


GENERAL   DISEASES.  367 

Oleate  of  mercury,  from  1  to  5  per  cent,  may  be  used  in  the 
same  way,  or  as  suggested  by  Eotch,  saturating  the  binder  with 
it  and  allowing  it  to  be  worn  for  48  hours.  Except  in  hospitals, 
this  method  of  treatment  is  very  unsatisfactory,  and  frequently 
severe  dermatitis  is  caused  by  the  inunctions. 

3.  By  injection,  can  be  given  bichloride  of  mercury  in  a 
2  per  cent  solution,  4  to  8  minims,  every  two  or  three  days. 
This  method  of  treatment  is  very  impractical  in  children.  A 
general  supervision  should  be  had  over  the  feeding,  habits  and 
sleep  of  the  patient.  Breast  milk  is  the  best  food,  but  not  from 
a  wet  nurse.  These  children  resist  infections  and  illnesses  very 
poorly,  hence  should  receive  the  best  nourishment  and  be  pro- 
tected from  contagions. 

The  treatment  of  syphilis  in  children  by  Salvarsan  (Ehrlich's 
606)  has  received  much  attention.  A  word  of  caution  cannot 
go  amiss  as  to  the  use  of  this  preparation  in  children.  It  has 
not  been  used  frequently  enough  for  the  last  word  to  have  been 
said  in  regard  to  it.  0.008  to  0.01  grams  per  kilogram  of  body 
weight  has  been  given  as  the  guide  for  infantile  dosage.  It 
may  be  given  intramuscularly  or  intravenously. 

Treatment  of  the  Special  Symptoms. — The  catarrhal  condition 
of  the  nose  causing  the  snuffles  requires  cleansing  washes,  Do- 
bell's  or  Seller's  solution  in  spray  or  douche,  followed  by  cal- 
omel insufflation  or  ointment  (1  part  to  20),  or  the  ung.  hydrar- 
gyri  ammoniati,  applied  to  the  cavities.  For  fissures  about  the 
mouth  and  rhagades  at  the  anus,  dry  calomel  is  of  benefit.  Diar- 
rhea may  need  treatment  by  discontinuance  of  the  mercury  and 
administration  of  bismuth  alone,  or  combined  with  Dover's  pow- 
der. 

Potassium  iodide  is  given  only  when  tertiary  symptoms  de- 
velop, hence  late  in  the  aflPection,  and  this  drug  pushed  to  point 
of  saturation. 


CHAPTER  XVI. 

CONTAGIOUS  DISEASES. 

ACUTE  EXANTHEMATA. 
MEASLES. 

Synonyms, — Rubeola,  morhilli,  fleckern,  masern. 

Definition. — Acute,  eruptive,  febrile  disease  caused  by  a  spe- 
cific contagion.  It  is  characterized  by  a  period  of  incubation, 
a  prodromal  stage,  with  catarrhal  symptoms  and  fever,  a  stage 
of  eruption  upon  the  skin  and  mucous  membrane  of  the  respira- 
tory tract,  and  a  stage  of  desquamation. 

Etiology. — Measles  is  perhaps  the  most  contagious  of  the  erup- 
tive diseases,  though  the  specific  organism  which  is  the  cause  of 
it  has  never  been  isolated.  The  organism  is  shorter  lived,  evi- 
dently, than  the  organism  which  causes  the  other  contagious  dis- 
eases. Occasionally  a  natural  immunity  is  seen.  One  attack 
usually  confers  immunity  although  recurrences  are  not  unusual. 
Children  under  six  months  of  age  are  less  susceptible  than 
older  ones,  and  adults  who  have  not  had  the  disease  in  childhood 
may  contract  it.  The  contagious  period  exists  throughout  the 
whole  course  of  the  disease,  though  the  early  acute  catarrhal 
stage  is  supposed  to  be  the  most   contagious. 

The  contagium  in  cities  rarely  entirely  dies  out.  It  is  very 
often  endemic  and  frequently  epidemic  in  character.  Because 
of  the  closer  housing  of  children  in  winter,  and  the  schools  being 
in  session  during  these  months,  it  is  more  prevalent  in  winter 
than  in  summer.  Apparently  it  is  possible  for  sporadic  cases  to 
develop  without  being  able  to  trace  the  infection.  It  has  been 
stated  that  the  contagium  cannot  be  carried  through  the  medium 
of  the  second  person  or  by  means  of  toys,  clothing,  etc.  No  milk 
borne  epidemics  have  been  recorded. 

The  practice  which  is  frequently  seen  in  cities  of  mothers  de- 
liberately exposing  their  children  to  the  contagium  of  any  of 

368 


CONTAGIOUS   DISEASES.  369 

the  exanthemata  is  one  which  cannot  be  too  violently  denounced. 

It  occurs  more  frequently  during  the  first  six  years  of  age. 

Mason  ^  has  reported  a  case  of  measles  in  utero.  The  mother 
was  delivered  after  a  typical  attack,  during  the  stage  of  des- 
quamation, and  the  child  showed  a  mottling  of  the  skin  and 
profuse  general  desquamation  which  persisted  for  20  days. 

Pathology. — The  chief  changes  are  in  the  mucous  membranes 
and  skin.  The  enanthem,  Koplik's  spots,  are  usually  present 
from  twenty-four  to  forty-eight  hours  before  the  exanthera. 
They  are  bright  red  spots  of  infiltration  in  the  mucous  membrane 
of  the  cheeks  and  lips.  A  round-cell  infiltration  occurs  in  the 
skin,  especially  around  the  hair  follicles  and  sweat  glands. 
There  is  an  engorgement  of  the  skin  capillaries  during  the  erup- 
tive stage.  The  conjunctivae  are  engorged  and  the  natural  se- 
cretion greatly  increased. 

Symptoms. — The  symptoms  are  generally  divided  into  three 
periods,  that  of  incubation,  prodrome  or  invasion,  eruption  and 
desquamation. 

Incubation — The  duration  of  the  period  of  incubation  is  from 
8  to  14  days,  the  eruption  usually  appearing  between  the  tenth 
and  fourteenth  days  after  exposure.  Usually  there  are  no  symp- 
toms referable  to  this  period,  until  48  to  52  hours  before  the 
appearance  of  the  eruption. 

The  Prodromal  Stage  or  Period  of  Invasion. — Two  or  three 
days.  The  first  symptoms  of  this  stage  are  usually  those  caused 
by  the  catarrh  of  the  respiratory  and  conjunctival  raucous  mem- 
branes. These  may  be  preceded  by  vomiting,  slight  headache, 
lassitude,  and  within  a  very  short  time  \\'till  be  seen  a  coryza  and 
reddening  of  the  eyes,  photophobia  is  pronounced,  a  harsh 
throaty  cough,  perhaps  some  hoarseness,  if  the  larynx  is  involved, 
with  more  or  less  bronchitis  developing  later. 

Beginning  with  the  advent  of  the  catarrhal  symptoms,  there 
is  a  rise  of  temperature,  varying  from  101°  to  104°  F.,  reaching 
its  height  with  the  full  appearance  of  the  eruption.  There  is  a 
slight  morning  remission  of  perhaps  1°  F.,  and  the  rise  in  the 
afternoon.  There  is  an  increased  drowsiness  and  almost  entire 
loss  of  appetite. 


^  Boston   Medical   and    Surgical   Journal,    October,    1908. 


370 


THE   DISEASES   OF    CHILDREN. 


Koplik  has  described  a  condition  which  is  present  upon  the 
mucous  membrane  of  the  mouth,  from  24  to  48  hours,  before  the 
appearance  of  the  eruption  upon  the  skin.  This,  as  described 
by  Koplik,  is  a  bright  red  spot  on  the  mucous  membrane  of  the 
cheek  and  lips,  in  the  center  of  which  is  a  minute  bluish-white 


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Fig.    70. — Measles. 

speck.  This  enanthem  can  only  be  seen  in  a  good  light,  and 
the  spots  are  very  characteristic  when  found,  and  Koplik  claims 
that  they  are  pathognomonic  of  measles. 

Eruption. — This  usually  appears  on  the  third  or  fourth  day. 
It  is  a  dusky  red,  pin-head  eruption,  usually  appearing  first 
upon  the  sides  of  the  neck  and  about  the  margin  of  the  hair, 
then  upon  the  chest  and  face,  and  gradually  the  whole  body  is 
covered.  The  eruption  is  much  less  prominent  upon  the  lower 
extremities  than  upon  the  body  and  arms.  It  sometimes  be- 
comes confluent.  It  varies  in  color  and  is  decidedly  more  dusky 
red  than  the  eruption  of  scarlet  fever.  The  rash  may  appear 
crescentic  in  form  but  the  spots  are  usually  irregular  in  out- 
line. 

In  the  very  severe  forms  measles  is  sometimes  designated  as 


CONTAGIOUS  DISEASES.  371 

black  measles,  the  eruption  is  of  a  bluish-black  color  which  is 
due  to  the  extravasation  of  blood  under  the  skin.  This  form 
is  also  called  malignant  measles. 

The  duration  of  the  eruption  upon  the  skin  varies  from  three 
to  five  days.  With  its  disappearance  there  is  left  a  slight  dis- 
coloration or  mottling  of  the  skin,  which  may  remain  for  several 
days. 

The  eruption  fades  first  from  the  mucous  membranes  and 
from  the  skin  in  the  order  in  which  it  first  made  its  appearance^ 
and  if  the  congestion  of  the  skin  has  been  very  intense  the  des- 
quamation begins  in  small  bran-like  scales  in  the  same  order. 
This  scaling  has  also  been  described  as  furfuraeeous.  The  des- 
quamation is  not  at  all  regular,  as  frequently  cases  are  seen  in 
which  no  desquamation  takes  place  at  all.  It  is  usually  pro- 
portionate to  the  amount  of  temperature  and  severity  of  the 
rash,  and  continues  from  four  days  to  a  week. 

As  the  rash  disappears,  all  of  the  symptoms  gradually  im- 
prove, the  fever  shows  a  regular  decline,  the  cough  improves, 
there  is  a  slight  return  of  appetite,  photophobia  disappears, 
though  the  eyes  may  remain  weak  for  some  time,  and  a  mild 
conjunctivitis  may  also  remain, 

At3rpical  Cases. — In  an  epidemic  many  varieties  of  cases  are 
encountered.  They  may  be  so  mild  as  to  go  practically  unrec- 
ognized, in  which  the  rash  is  very  slight,  there  is  very  .little  fever 
and  few  catarrhal  symptoms.  Frequently,  unless  these  cases 
occur  in  an  epidemic,  they  go  unrecognized. 

Malignant. — This  form  is  decidedly  the  most  fatal  and  occurs 
in  children  with  very  little  resistance.  The  eruption  is  very 
severe,  frequently  of  the  hemorrhagic  type,  ordinarily  called 
black  measles.  Sometimes  the  malignant  form  may  have  but 
little  rash,  and  the  severe  symptoms  are  caused  by  the  severity 
of  the  complications.  In  this  form  of  cases,  pneumonia  is  the 
principal  complication  and  the  cause  of  the  majority  of  the 
fatalities.  In  this  the  rash  not  infrequently  disappears  more  or 
less  rapidly.  The  laity  look  upon  this  condition  as  ''striking 
in"  of  the  rash,  considering  it  the  cause  of  the  complication. 
This  phenomenon  is  a  result  of  the  complication  and  not  the 
cause. 


372 


THE   DISEASES  OF    CHILDREN, 


Complications  and  Sequelae. — The  chief  complications  are  those 
of  the  respiratory  tract ;  bronchitis  and  bronchopneumonia.  The 
jQunger  the  child,  the  more  liable  it  is  to  develop  pneumonia, 
and  it  is  the  most  frequent  cause  of  death.     This  complication 


Fig.    71. — Measles   with   complicating   pneumonia. 

is  due  to  invasion  of  the  respiratory  mucous  membranes  by  the 
pneumococcus  and  the  streptococcus,  and  in  practically  every 
fatal  case  of  measles,  more  or  less  bronchopneumonia  will  be 
found. 

Catarrhal  laryngitis  and  pharyngitis  are  very  often  present, 
and  in  these  cases  in  which  this  is  a  feature  an  invasion  of  the 
middle  ear  is  more  often  present.  Spasmodic  croup  has  been 
reported  as  a  complication.  Otitis  media  is  a  frequent  compli- 
cation. It  has  not  been  my  experience  to  see  many  cases  of 
pseudomembrane  upon  the  tonsils  or  pharynx  in  measles,  though 
it  has  been  frequently  recorded  by  various  authors.  A  cellulitis 
of  the  skin  of  the  external  auditory  canal  may  occur.  Conjunc- 
tivitis is  a  very  frequent  complication.  There  is  always  a  con- 
gestion of  the  conjunctiva  and  this  may  persist  especially  in 


CONTAGIOUS  DISEASES.  373 

poorly-nourished  children  for  some  time  after  the  disappearance 
of  the  rash. 

Tuberculosis. — Because  of  the  catarrhal  condition  and  adenitis 
resulting  from  measles,  the  soil  is  ripe  for  the  absorption  of 
the  tubercle  bacilli  and  their  development.  The  frequent  occur- 
rence of  bronchopneumonia  also  offers  a  site  for  their  develop- 
ment and  propagation.  The  tubercular  process  may  have  been 
latent  and  an  attack  of  measles  all  that  was  needed  for  its  light- 
ing up. 

Cutaneous  Complications. — ^A  general  pruritic  condition  of  the 
skin  may  be  present  in  measles,  especially  during  the  early 
eruptive  stage.  This  may  be  partly  due  to  a  sudamina,  or 
blocking  of  the  sweat  glands,  and  consequent  formation  of 
minute  vesicles  and  great  itching.  Herpes  labialis  and  facialis 
is  frequently  seen,  and  urticaria  is  also  a  complication.  This 
may  take  the  form  of  the  large  wheals  or  the  minute  papules 
which  itch  greatly.  In  the  grave  or  hemorrhagic  form  noma 
may  develop,  due  to  an  infective  embolus  finding  lodgment  in 
the  cheek  or  perhaps  an  extension  from  an  ulcerative  stomatitis. 

Prognosis. — This  depends  to  a  great  extent  on  the  individual 
child,  on  the  character  of  the  epidemic  or  endemic,  the  age  of 
the  child  and  the  complications.  The  mortality  from  measles 
itself  is  not  very  high.  The  occurrence  of  pneumonia  or  any 
bronchial  irritation  renders  the  prognosis  much  less  favorable. 
This  one  complication  is  the  cause  of  the  largest  percentage  of 
deaths  in  measles. 

The  early  evidence  of  toxemia  makes  the  prognosis  less 
favorable. 

The  uncomplicated  form  of  measles  in  a  child  over  four  is 
usually  not  very  severe. 

Prognosis  is  bad  in  cases  with  such  complications  as  laryn- 
gitis, otitis,  diphtheria,  hemorrhages  in  the  skin. 

Diagnosis. — With  the  first  description  of  the  buccal  eruption 
in  measles  by  Koplik,  the  diagnosis  became  much  more  easily 
made,  for  in  connection  with  the  catarrhal  symptoms  present 
the  diagnosis  can  be  made  even  before  the  rash  has  appeared. 

Rubella  is  apt  to  be  confounded  with  measles,  as  the  rash  is 
very  similar  indeed.     In  this  condition,  however,  all  the  symp- 


374  THE  DISEASES  OF   CHILDREN, 

toms  are  less  severe,  little  or  no  fever,  very  slight  catarrhal 
symptoms,  the  rash  appears  more  quickly  and  remains  out  a 
shorter  time,  and  desquamation  is  rarely  seen.  The  post  cervical 
adenitis,  is  a  characteristic  sign  in  rubella  and  not  a  constant 
one  in  measles. 

Scarlet  fever  is  less  apt  to  be  confused  as  the  rash  is  so  en- 
tirely different.  There  are  but  few  if  any  catarrhal  symptoms 
or  cough  in  the  early  stages.  The  scarlatinal  throat  and  tongue 
are  not  present  in  measles. 

Drug  eruptio7is  and  the  eruption  due  to  an  intestinal  toxemia, 
the  so-called  ''stomach  rash,"  may  cause  some  confusion  in 
diagnosis.  Rashes  occur  from  the  administration  of  antipyrin, 
quinin  and  chloral  and  the  antitoxin  sera.  In  all  of  these  the 
catarrhal  symptoms  are  absent,  usually  but  little  fever,  and 
not  suggestive  of  measles  in  its  range. 

Treatment.  Prophylaxis. — As  already  stated,  there  is  a  wide- 
spread belief  indulged  in  that  all  children  should  have  the  con- 
tagious diseases,  unfortunately,  by  some  physicians,  and  too 
many  cities  having  the  contagious  disease  placard  system  omit 
measles  from  the  list  of  diseases  to  be  reported  and  placarded. 

This  lack  of  concern  results  in  lax  efforts  at  isolation  and 
many  unnecessary  cases  and  deaths  occur. 

Strict  quarantine  should  be  maintained  and  the  child  isolated 
as  soon  as  a  history  of  definite  exposure  has  become  known. 
Then  when  it  is  ready  to  be  relieved  of  quarantine,  when  des- 
quamation has  ceased,  and  no  catarrhal  symptoms  persist,  the 
final  cleansing  bath  and  room  preparation  should  be  insisted 
upon.     Quarantine  should  be  maintained  at  least  three  weeks. 

Uncomplicated  measles  is  a  more  or  less  self-limited  disease. 
The  curative  measures  will  therefore  be  largely  directed  toward 
the  prevention  of  complications.  Hence,  to  prevent  pulmonary 
involvement,  the  child  must  be  kept  in  bed  in  a  large,  airy  room, 
with  plenty  of  fresh  air.  The  light  must  not  shine  direct  in 
the  eyes,  but  there  is  no  necessity  of  keeping  the  room  entirely 
dark.  The  head  of  the  bed  should  be  turned  toward  the  light 
and  covered  with  a  sheet  to  keep  out  the  bright  light. 

The  eyes  should  be  bathed  at  least  twice  a  day  witli  a  warm 
ten   per   cent   solution   of   boracic   acid.     The   nose   should   be 


CONTAGIOUS   DISEASES.         •  375 

sprayed  or  irrigated  with  the  same  solution  or  with  a  normal 
salt  solution. 

Fresh  air  should  be  insisted  upon.  The  child  should  be  pro- 
tected with  sufificient  clothing  and  outside  fresh  air  let  in. 

The  harsh,  dry  cough  which  is  apt  to  keep  the  child  awake 
should  be  controlled.  Moist  air,  obtained  by  keeping  a  steam 
spray  going  in  the  room  near  the  bed  by  a  croup  kettle  or  steam 
atomizer  is  of  great  assistance  to  this  end.  To  the  water  can 
be  added  tinct.  benzoin  comp.  (5i  to  Oi)  or  oil  of  eucalyptus 
(oss  to  Oi),  both  of  which,  in  connection  with  the  moist  air, 
have  a  sedative  action  on  the  mucous  membrane  of  the  throat 
and  larynx.  Codeine  in  %  to  14  gr.  doses,  plain  or  with  a  tea- 
spoonful  of  brown  mixture,  can  be  used  with  great  benefit  for 
the  cough.  Wet,  cold  compresses  to  the  throat,  protected  by 
a  dry  flannel,  wider  than  the  wet  one,  and  changed  every  four 
to  six  hours,  will  be  found  of  service  also. 

If,  during  the  early  eruptive  stage,  there  is  great  restlessness., 
3  to  5  grain  doses  of  potassium  or  strontium  bromide  can  be 
given  at  three-hour  intervals,  or  small  doses  of  phenacetine. 

Unless  there  is  hyperpyrexia  the  fever  needs  no  attention.  If 
it  remains  persistently  above  103°  F.  it  is  best  controlled  by  full- 
tub  baths,  wet  pack  or  sponge  baths.  It  is  not  advisable  to  give 
coal-tar  products  in  any  form.  Enemas,  when  needed  for  acute 
constipation,  should  be  given  cool  (70°  to  80°  F.)  in  the  presence 
of  high  temperature. 

In  those  cases  in  which  the  eruption  is  slow  in  appearing  a 
warm  bath  (100°  F.)  will  be  found  of  service.  It  quiets  rest- 
lessness and  favors  the  appearance  of  the  rash. 

In  measles,  as  in  the  other  exanthemata,  keeping  the  child 
wrapped  up  too  warmly  in  a  "hot,  unventilated  room,  and  the 
withholding  of  cool  drinks  and  giving  hot  or  warm  solutions  in 
order  to  ''bring  out  the  rash'-'  should  not  be  tolerated. 

"While  nephritis  is  an  unusual  complication  in  measles,  it  can 
occur  upon  exposure,  and  during  convalescence  the  child  should 
be  protected  from  undue  exposure  to  cold  draughts. 

Bronchopneumonia  is  evidenced  by  a  sharp  rise  in  the  tem- 
perature and  an  increase  in  pulse  and  respiration  ratio  and 
evidence   of   prostration.     The   treatment   of   this   complication 


376  THE   DISEASES   OF    CHILDREN. 

does  not  differ  from  a  bronchopneumonia  occurring  primarily. 

Iron  and  cod  liver  oil  are  indicated  in  the  convalescence, 
especially  when  a  bronchial  irritation  and  anemia  persist. 

During  the  stage  of  desquamation  the  child  should  have  a 
daily  bath,  in  a  tub  if  possible,  and  after  drying  should  receive 
a  general  anointing  with  an  unguent,  a  1  per  cent  carbolic  acid 
in  vaseline.  This  is  useful  to  allay  itching  and  as  an  antiseptic 
also. 

GERMAN  MEASLES. 

Synonyms. — Rotheln,  Rubella. 

This  is  an  acute  specific,  infectious,  eruptive  disease  usually  of 
mild  nature,  and  of  shorter  duration  than  the  other  exanthemata, 
and  not  at  all  related  to  them.  It  does  not  protect  the  individ- 
ual from  any  of  the  other  exanthemata.  It  is  characterized  by 
a  period  of  incubation,  a  prodromal  stage,  followed  by  an  erup- 
tion. 

Etiology. — The  bacteriology  of  this  disease  is  not  known.  It 
may  be  sporadic  but  is  usually  epidemic,  and  may  occur  at  any 
age.  It  is  more  frequent  in  children  from  two  to  five  years  of 
age.  I  have  seen  an  epidemic  of  rubella  and  rubeola  in  an  in- 
stitution at  the  same  time.  A  child  would  have  an  attack  of 
one  form,  and  in  a  few  days  return  with  a  typical  attack  of  the 
other.  In  some  cases  German  measles  preceded ;  in  others 
measles. 

Symptoms. — The  period  of  incubation  is  more  variable  than 
in  the  other  exanthemata.  The  average  is  about  15  days,  vary- 
ing from  5  to  18  days.  There  are,  as  a  rule,  no  symptoms 
during  this  stage. 

During  the  stage  of  invasion,  which  may  last  from  a  few 
hours  to  two  or  three  days,  the  child  may  be  restless  and  peevish, 
complain  of  headache  and  sore  throat,  evidence  some  catarrhal 
symptoms,  lacrimation  and  cough,  but  these  latter  are  by  no 
means  constant.  As  a  rule  there  is  from  1°  F.  to  2°  F.  rise  in 
temperature  during  this  stage,  the  fever  being  higher  as  soon  as 
the  rash  appears,  gradually  subsiding  when  the  rash  is  pro- 
nounced. Stage  of  eruption  begins  with  the  appearance  of  the 
rash  on  the  face  and  neck,  soon  spreading  to  the  trunk  and  arms, 
and  finally  very  sparsely,  as  a  rule,  upon  the  legs,  the  rash 


CONTAGIOUS   DISEASES. 


377 


reaching  its  height  within  36  hours.  By  the  time  the  rash  ap- 
pears upon  the  legs  it  has  begun  to  fade  on  the  face  and  neck. 
It  is  not  unusual  for  the  rash  to  have  entirely  disappeared 
within  48  hours  from  its  onset. 

The  rash  appears  as  a  faint  red  macule,  slightly  larger  than 


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a  pin  head,  and  becomes  a  rose-red  in  color.  There  are  areas 
of  normal  skin  between  the  macular  spots,  unless  the  eruption 
becomes  confluent,  which  is  unusual. 

This  is  the  variety  of  rubella  which  is  usually  referred  to  as 
the  measles  variety. 

The  other  variety  is  described  as  the  scarlatmafonn  variety, 
the  exanthem  resembling  that  seen  in  scarlet  fever.  The  differ- 
ence between  the  two  forms  of  rubella  are  simply  in  the  character 
of  the  rash.  In  the  scarlatinaform  variety  the  rash  is  much 
more  widely  distributed,  does  not  occur  in  such  large  macular 
spots,  and  the  skin  has  a  more  uniform  redness. 

The  mucous  membrane  of  the  mouth  and  throat  is  reddened 
but  there  are  no  Koplik's  spots. 


378  THE   DISEASES   OF    CHILDREN. 

In  rubella  there  is  almost  constantly  found  an  adenitis,  the 
lymph  nodes  most  frequently  found  enlarged  being  those  of  the 
neck,  both  back  and  front.  This  symptom  occurs  in  fully 
90  per  cent  of  cases,  and  is  a  valuable  diagnostic  sign,  as  an 
adenitis  is  not  nearly  so  frequent  in  the  other  varieties  of  ex- 
anthemata. The  swelling  of  these  glands  quickly  subsides  after 
the  fever  and  rash  disappear. 

Desquamation  in  rubella  is  not  as  regularly  seen  as  in  measles 
and  scarlatina.  Like  in  measles,  the  amount  of  the  desquama- 
tion is  proportionate  to  the  severity  of  the  eruption,  and  is 
bran-like  and  scaly,  and  is  not  prolonged,  rarely  lasting  more 
than  a  week.  The  desquamation  may  be  simply  a  roughening 
of  the  skin  and  not  at  all  decided. 

Complications  and  Sequelae. — These  are  very  infrequent  and 
rarely  severe.  A  gland  or  group  of  glands  may  break  down  and 
require  lancing  to  evacuate  the  pus.  Stomatitis  is  sometimes 
seen,  but  is  never  of  the  gangrenous  type;  pneumonia  is  much 
less  frequent  than  in  measles;  otitis  media  may  occur. 

Diagnosis. — This  is  frequently  very  difficult  indeed.  It  must 
be  made  from  measles,  scarlet  fever  and  vaccinia.  When  it  is 
remembered  that  rubella  is  most  apt  to  occur  in  epidemics,  all 
its  symptoms  are  less  severe,  rash  not  so  profuse  and  more  dis- 
crete; less  fever;  adenitis  present  in  almost  every  case  and  has 
few  complications  or  sequelae,  the  diagnosis  is  usually  easy. 

Prognosis. — This  is  almost  universally  good,  especially  so 
where  the  hygienic  conditions  are  all  right. 

Treatment. — But  little  treatment  is  required,  confinement  to 
bed  during  the  eruptive  stage,  and  while  the  fever  lasts,  in  a 
properly  ventilated  and  heated  room;  cleansing  sprays  and 
washes  for  nose  and  throat,  attention  to  bowels;  bathing,  both 
for  cleansing  and  antipyretic  purposes,  and  anointing  during 
the  stage  of  desquamation. 

SCARLATINA. 

Synonym. — Scarlet  fever,  scharlach. 

Definition. — An  acute,  specific,  highly  contagious  and  infec- 
tious, eruptive,  febrile  disease. 

Etiology. — The  specific  organism,  the  cause  of  scarlet  fever, 


CONTAGIOUS  DISEASES.  379 

has  not  yet  been  isolated,  but  it  is  unquestionably  due  to  an 
organism,  and  associated  with  it  is  the  streptococcus  in  a  large 
percentage  of  cases.  It  is  the  streptococcus  which  is  the  cause 
of  so  many  of  the  complications  of  scarlet  fever,  and  it  is  prob- 
ably the  mixed  infection  which  is  present  that  accounts  for  the 
severit}^  of  so  many  cases. 

The  contagium  lives  for  a  long  period  of  time,  and  can  be 
carried  great  distances  by  articles  handled  by  the  sick  child. 
A  number  of  epidemics  of  scarlet  fever  have  been  traced  to 
milk  as  the  carrier  of  the  infection,  and  in  every  epidemic  the 
milk  supply  should  be  closely  investigated. 

Scarlet  fever  is  most  frequent  between  one  and  five  years  of 
age,  though  cases  are  on  record  in  children  much  younger.  It 
is  rare  before  the  sixth  month. 

A  natural  immunity  may  exist.  Second  attacks  are  not  un- 
common.    Adults  are  less  susceptible  than  children. 

The  discharges  from  the  nose,  mouth,  throat  and  bronchi  are 
most  virulent  as  carriers  of  the  contagium,  the  desquamated 
skin  being  also  a  disseminator  of  it.  Hence,  scarlatina  is  con- 
tagious throughout  all  its  course.  The  port  of  entry  of  the  con- 
tagium is  most  likely  the  nasopharynx. 

As  in  measles,  because  of  the  close  housing  and  crowded  school 
rooms,  during  winter,  more  cases  occur  in  this  season  than  dur- 
ing the  summer  months.  I  have  never  seen  a  ease  of  scarlatina 
in  a  negro,  and  I  believe  it  is  very  uncommon  in  this  race. 

In  spite  of  the  long  life  of  the  contagium,  scarlatina  is  not 
nearly  so  prevalent  as  measles.  I  have  frequently  seen  one  case 
of  scarlatina  removed  from  a  dormitory  of  children  without 
the  second  case  developing,  while  in  epidemics  of  measles  prac- 
tically all  the  children  would  be  attacked. 

The  mucous  discharges  from  the  nose  and  mouth  and  the  des- 
quamated skin  are  the  chief  sources  of  contagion.  Hence,  any- 
thing handled  by  the  patient,  especially  during  the  stage  of  des- 
quamation should  be  carefully  disinfected  or  destroyed.  The 
bedding  from  tlie  child's  bed,  the  clothes  and  night  dress  should 
be  most  carefully  disinfected. 

Symptoms.  Period  of  Incuhatio7i. — This  is  usually  shorter 
than  the  other  eruptive  diseases,  lasting  from  a  few  hours  to 


380  THE   DISEASES   OF    CHILDREN. 

6  to  10  days.  The  onset  of  the  stage  of  invasion  is  short  and 
sudden,  it  appearing  to  attack  a  child  apparently  well.  It  is 
attended  by  sore  throat,  vomiting,  rigors,  fever,  rapid  pulse, 
headache,  and  loss  of  appetite.  Infrequently  convulsions  may 
usher  in  an  attack  in  younger  children. 

The  tongue  is  covered  quite  heavily  with  a  grayish-white  coat, 
with  a  cleaning  off  of  the  edges  at  the  beginning  of  the  stage  of 
eruption.  About  this  time  also  the  red  papillas  begin  to  show 
through  this  coat,  which  at  the  tip  becomes  quite  thin,  giving  to 
the  tongue  the  appearance  of  a  strawberry.  This  is  considered 
a  confirmatory  sign  of  scarlet  fever.  About  the  fourth  day  of 
the  rash  the  tongue  is  clean  and  papillas  quite  prominent.  At 
this  time  the  tonsils  are  swollen  and  red;  perhaps  a  slight  exu- 
date may  have  appeared  on  one  or  both. 

Stage  of  Eruption. — The  eruption  appears  usually  within  24 
hours  after  the  first  symptom,  which  as  a  rule  is  the  vomiting, 
is  noted.  It  comes  out  on  the  neck  first,  and  about  the  same 
time  spreads  to  the  chest  and  faintly  on  the  face,  and  shortly 
afterward  the  entire  body  is  covered.  It  is  more  distinct  on  the 
flexor  surfaces  of  the  extremities  than  the  extensors.  The  flexor 
surfaces  of  the  joints  may  not  present  the  typical  rash. 

The  scarlatinal  rash  is  a  minute  punctate  elevation  on  the 
skin,  with  areas  of  normal  skin  between,  but  the  skin  has  the 
appearance  of  having  a  uniformly  dull  red  hue  when  viewed 
at  some  distance.  This  is  due  to  the  erythematous  background. 
The  skin  is  blanched  on  pressure,  the  dull  red  color  promptly 
appearing  on  removal  of  this.  There  may  be  large  areas  of  nor- 
mal skin,  and  the  rash  looks  patchy.  It  is  impossible  to  make  a 
diagnosis  of  this  rash  except  in  a  good  light.  Frequently  minute 
vesicles  may  be  seen.     Itching  is  often  present. 

The  rash  disappears  first  from  the  parts  of  the  body  where 
it  first  appeared,  leaving  the  skin  rough,  and  this  is  followed 
by  a  general  desquamation.  The  eruption  lasts  from  three  to 
seven  days,  but  undoubtedly  cases  are  encountered  in  which 
the  rash  is  so  slight  as  to  go  entirely  unnoticed. 

I  have  had  such  a  ease  under  observation.  The  prominent 
symptom  was  the  gangrenous  tonsillitis,  and  the  boy  was  treated 
for  this  entirely.     About  10  days  later,  after  being  dismissed 


CONTAGIOUS   DISEASES.  381 

with  all  symptoms  in  the  throat  absent,  he  consulted  me  again 
to  ask  why  his  hands  were  peeling,  and  exhibited  a  hand  which 
had  the  typical  scarlatinal  desquamation,  the  skin  coming  off 
in  large  scales. 

Desquamation. — This  begins  upon  the  parts  where  the  rash 
first  appeared.  On  the  body  the  peeling  is  furfuraceous,  the 
skin  coming  off  in  larger  scales  than  in  measles.  These  scales 
are  perforated  and  they  have  been  referred  to  as  "pin-holing." 

Desquamation  begins  with  the  subsidence  of  the  fever.  The 
typical  scarlatinal  desquamation  begins  upon  the  hands  and  feet 
soon  afterward.  Cases  have  been  reported  where  entire  casts  of 
the  hands  and  feet  were  thrown  off.  It  begins  at  the  free  border 
of  the  nails.  This  form  is  referred  to  as  a  lamelhsa.  The 
finger  nails  show  characteristic  signs  in  this  stage.  If  the  skin  at 
the  matrix  margin  of  the  nail  is  pushed  back  a  cracked  line  is 
noted  extending  up  to  the  matrix.  This  is  best  seen  on  the 
thumb.  No  desquamation  whatever  may  follow  an  unquestioned 
ease.  The  appearance  of  the  finger  nails  during  desquamation 
has  been  described  as  characteristic.  In  the  sub-ungual  spaces 
with  the  finger  tips  pushed  back,  is  seen  a  cracked  line  extending 
to  the  fingers. 

The  duration  of  desquamation  is  from  two  to  ten  weeks,  the 
average  being  about  five  weeks. 

Fever. — There  is  no  typical  temperature  curve  in, this  disease, 
but  it  is  high  in  proportion  to  the  streptococcic  involvement  and 
reaches  its  height  by  the  second  or  third  day.  If  everything  is 
progressing  favorably  the  temperature  begins  to  fall  wdth  the 
recession  of  the  rash,  and  it  rises  with  the  development  of  any 
complications. 

The  pulse  is  almost  always  rapid,  out  of  proportion  to  the 
temperature  and  respiration  ratio.  There  is  a  general  enlarge- 
ment of  the  superficial  lymph  nodes,  not  limited  as  the  enlarge- 
ment is  in  German  measles  to  the  cervical  region,  but  appearing 
in  the  groin,  and  axilla  also. 

The  throat  is  congested  from  the  rash  on  the  mucous  mem- 
branes quite  early,  and  an  exudate  is  very  often  seen  after  the 
second  or  third  day,  principally  upon  the  tonsils,  but  it  may  ex- 
tend to  the  uvula  and  posterior  pharyngeal  wall.     These  exudates 


382  THE  DISEASES  OF   CHILDREN. 

may  be  due  to  the  streptococci  or  to  the  diphtheria  bacillus,  and 
a  culture  is  generally  necessary  to  decide  to  which  organisms  it 
is  due,  these  cases  being  known  as  the  original  form. 

The  urine  should  be  regularly  examined  during  scarlatina. 
During  the  height  of  the  eruption  the  quantity  is  reduced,  but 
at  the  end  of  the  first  week  it  returns  to  normal.  It  is  not  un- 
common for  albumin  to  be  present  throughout  the  disease  in 
small  quantities  and  sometimes  the  reilal  derivatives,  epithelium, 
blood,  granular  and  hyaline  easts,  but  they  are  found  more  fre- 
quently during  the  stage  of  desquamation.  An  acute  Bright 's- 
disease  is  not  regularly  seen,  but  it  does  occur  as  a  complication 
very  frequently. 

The  hlood  shows  a  diminished  number  of  red  blood  cells  and 
a  leucocytosis  is  present  both  before  the  rash  appears  and 
throughout  the  entire  course  of  the  disease.  In  the  anginal 
form  this  sign  is  more  marked.  There  is  an  increase  in  the  poly- 
nuclears  and  the  eosinophiles  are  absent. 

Complications.  Otitis. — A  purulent  inflammation  of  the  mid- 
dle ear  is  one  of  the  commonest  complications.  It  may  occur 
in  cases  in  which  there  is  no  tonsillar  exudate,  and  a  spontaneous 
rupture  of  the  drum  is  nearly  always  the  result.  Scarlatinal 
otitis  is  one  of  the  most  frequent  causes  of  deafness,  and  is  a 
complication  to  be  dreaded.  Its  presence  is  usually  indicated 
by  deafness,  earache  and  rise  in  temperature,  followed  soon 
after  by  a  spontaneous  rupture  of  the  drum.  The  presence  of 
the  pus  in  the  auditory  canal  or  the  staining  of  the  pillow  no- 
ticed when  the  child  awakens  may  be  the  first  evidence  of  this 
trouble.  Frequent  examinations  of  the  ear  drums  are  import- 
ant, and  a  paracentesis  done  as  soon  as  a  bulging  is  noted. 

Angina. — This  may  be  either  a  severe  congestion  of  the  mu- 
cous membrane  of  the  throat,  a  severe  tonsillitis  with  enlarge- 
ment of  the  tonsils,  a  pharyngitis  and  laryngitis,  or  a  gangre- 
nous condition  of  the  tonsils.  It  is  not  infrequent  that  scarlatina 
sine  exanthemata  is  at  first  diagnosed  as  a  simple  catarrhal  or  a 
follicular  tonsillitis,  as  an  exudate  in  the  tonsillar  crypts  is  very 
frequent.  Where  the  exudate  is  very  thick,  late  in  the  eruptive 
stage,  the  chief  organism  is  the  diphtheria  bacillus.  The  diph- 
theritic form  usually  reaches  its  height  at  the  end  of  the  first 


CONTAGIOUS   DISEASES.  383 

week,  and  the  symptoms  and  appearance  of  the  throat  are  the 
same  as  in  uncomplicated  diphtheria. 

Adenitis. — The  inflammation  of  the  lymph  nodes  may  be 
quite  severe  and  suppuration  may  occur.  This  enlargement  of 
the  glands  at  the  angle  of  the  jaw  and  of  the  neck  may  be  enough 
to  cause  pressure  on  the  larynx  and  dyspnea,  or  the  strepto- 
coccic invasion  of  the  cellular  tissue  of  throat  and  larynx, 
sufficient  to  necessitate  intubation.  I  have  had  such  a  case  un- 
der my  observation. 

The  child  had  a  severe  scarlatina  with  first  a  double  suppurative  otitis 
media,  then  an  albuminuria,  followed  by  a  membranous  angina  and  an  ob- 
structive laryngitis.  This  condition  necessitated  an  intubation  which  re- 
lieved the  symptoms  for  a  time  only,  the  obstruction  from  cellular  infiltra- 
tion both  above  and  below  the  tube  being  so  great  as  to  make  the  removal 
of  the  tube  imperative.  This  was  done  with  great  difficulty.  Dyspnea  be- 
ing decided  and  relief  necessary  to  prolong  life,  tracheotomy  was  done.  A 
bronchopneumonia  developed  shortly  after  and  death  from  heart  failure 
relieved  the  sufferings  of  the  child. 

Arthritis. — A  streptococcic  inflammation  of  the  joints  is  some- 
times seen,  formerly  diagnosed  as  a  scarlatinal  rheumatism.  It 
is  a  synovitis  of  streptococcic  origin.  Surgery  may  be  found 
necessary  where  purulent  effusion  in  the  joint  is  present.  Fixa- 
tion of  the  joint  is  imperative. 

Kidneys. — The  kidneys  are  involved  in  scarlatina  in  a  large 
percentage  of  cases,  the  symptoms  appearing  usually  from  the 
end  of  the  second  to  the  middle  of  the  fourth  week  of  the  dis- 
ease. A  diminution  in  the  quantity  of  the  urine,  edema  of  the 
eyelids,  face  and  ankles  is  noted,  and  an  examination  of  the  urine 
shows  all  the  abnormalities  found  in  the  urine  of  an  acute  neph- 
ritis.    Uremia  may  occur  in  the  severer  forms  of  nephritis. 

Frequent  or  daily  examination  of  the  urine  from  the  begin- 
ning of  the  second  week  is  desirable,  as  albumin  will  often  be 
present  before  symptoms  of  the  nephritis  appear. 

Lungs. — A  bronchitis  is  not  as  frequent  a  complication  in 
scarlatina  as  in  measles,  but  it  sometimes  occurs.  Bronchopneu- 
monia is  more  often  seen,  especially  in  those  cases  in  which  the 
streptococci  are  present  in  large  numbers. 

Other    complications    occasionally    occurring    are    an    endo' 


384  THE   DISEASES  OF    CHILDREN. 

carditis,  in  those  cases  of  streptococcic  synovitis  especially;  a 
myocarditis  in  severe  septic  infection,  as  in  gangrenous  sto- 
matatis;  meningitis  in  the  course  of  the  disease  or  following  a 
mastoid  involvement  as  a  complication  of  otitis  media;  convul- 
sions, either  as  an  initial  symptom  or  during  the  course  of  the 
disease;  an  irritable  condition  of  the  stomach,  recurrent  vomit- 
ing, anorexia,  diarrhea.  Vomiting  as  the  first  symptom,  occurs 
quite  regularly.  As  seqiielce  there  may  be  a  chronic  tonsillitis 
with  enlargement,  and  perhaps  the  development  of  adenoids; 
deafness,  already  referred  to ;  mastoiditis ;  chronic  nephritis ;  and 
endocarditis. 

Diagnosis. — In  the  irregular  forms  of  scarlatina  with  but 
little  rash,  which  is  of  very  short  duration,  the  diagnosis  may 
be  very  uncertain,  as  in  the  ease  of  gangrenous  tonsillitis  re- 
ferred to,  or  not  suspected  at  all,  and  not  made  until  desquama- 
tion begins. 

Diagnosis  must  be  made  from  erythematous  rashes,  either 
caused  by  external  irritants  or  from  the  action  of  certain  drugs 
or  poisons  taken  internally.  Belladonna,  quinin,  salicylic  acid, 
bromides,  or  veronal  are  among  the  drugs  causing  rashes.  In 
these  rashes  there  are  practically  no  symptoms  except  the  rash. 
Scarlatinaform  rashes  may  follow  the  injection  of  the  serums 
especially  diphtheria  antitoxin. 

The  typical  cases,  however,  should  be  easy  of  diagnosis.  The 
associated  symptoms  are  characteristic,  vomiting,  fever,  typical 
rash,  sore  throat  and  strawberry  tongue. 

Prognosis. — In  uncomplicated  eases  this  is  good.  Holt  gives 
the  general  mortality  from  12  per  cent  to  14  per  cent  in  uncom- 
plicated cases,  and  cases  under  five  years  from  20  to  30  per  cent, 
others  give  the  mortality  in  several  epidemics  as  3  per  cent. 
Hence,  the  prognosis  is  greatly  influenced  by  the  occurrence  of 
complications  and  by  the  age  of  the  patient. 

Treatment. — Prophylaxis.  Empirically  we  have  learned  that 
scarlatina  is  much  less  contagious  than  measles,  and  that  the 
contagium  is  very  much  longer  lived,  hence  the  special  indica- 
tions are  strict  isolation  and  quarantine  of  every  ease  of  scarla- 
tina, and  most  thorough  disinfection  after  dismissal  of  the  case, 
of  room,  bedding,  dishes,  clothing,  etc.     Isolation  should  begin 


CONTAGIOUS  DISEASES.  385 

as  soon  as  it  is  known  the  child  has  been  exposed  to  scarlatina, 
even  though  the  exposure  has  been  during  the  incubation  stage, 
when  it  is  believed  the  least  danger  is  present.  Other  children 
in  the  house  should  remain  away  from  school,  and  should  not 
be  sent  away  from  home  in  order  to  continue  at  school  because 
of  the  possibility  of  late  development  of  scarlatina  in  them.  AH 
intercourse  between  the  sick  room  and  the  rest  of  the  house 
should  be  prevented,  and  the  physician  should  protect  himself 
by  a  long  gown  before  entering  the  room  and  cover  head  with 
head  gauze  or  cap.  The  gown  should  be  taken  off  after  leaving 
the  room.     The  hands  and  face  should  be  then  carefully  washed. 

Quarantine  should  be  prolonged  during  the  entire  stage  of 
desquamation,  and  not  until  the  feet  and  hands  are  entirely  free 
from  roughness  and  scales  should  it  be  raised.  The  persistence 
of  the  discharge  from  an  otitis  or  a  chronic  nasal  discharge  or 
pharyngitis  is  sufficient  ground  for  maintaining  the  quarantine. 

Placarding  of  houses  is  most  important  and  this  regulation 
will  be  made  a  law  if  the  physicians  of  a  community  demand  it. 
The  medical  inspection  of  public  school  children  is  a  measure 
which  will  prevent  many  epidemics  of  scarlatina  and  measles, 
as  the  early  recognition  of  the  sore  throat  of  one,  catarrhal  symp- 
toms and  buccal  eruption  of  the  other,  will  be  enough  to  remove 
the  child  from  the  class  long  enough  to  have  the  tentative  diag- 
nosis confirmed  or  disproved.  Attention  to  details  in  the  choice 
and  conduct  of  the  sick  room  should  be  given  by  the  physician. 
A  room  as  cheerful  as  possible  should  be  chosen,  but  removed 
from  the  rest  of  the  house,  on  the  top  floor,  or  at  the  back,  near 
enough  to  the  toilet  and  bathroom  as  not  to  necessitate  the  carry- 
ing through  all  the  halls  of  the  discharges,  etc.  All  unnecessary 
hangings  and  the  carpet  should  be  removed.  A  tub  should  be 
provided  in  the  room  containing  enough  antiseptic  solution 
(1:2000  bichloride  or  1:20  carbolic  acid  solution),  in  which  all 
bed  linen  and  clothes  can  be  soaked  before  they  are  removed  to 
be  washed.  They  should  then  be  boiled  separately  from  the  rest 
of  the  wash.  Scraps  of  old  sheets  or  tablecloths  or  squares 
of  gauze  are  best  used  for  handkerchiefs,  and  burned  after- 
ward. 

A  sheet  should  be  hung  from  the  top  of  the  door  frame  out- 


386  THE  DISEASES  OP   CHILDREN. 

side  the  door  to  lessen  air  eommunication  with  the  rest  of  the 
house. 

After  desquamation  has  begun  general  inunction  of  the  skin 
is  of  service  in  preventing  the  dissemination  of  the  scales.  Plain 
vaseline  is  as  good  as  anything  as  it  is  doubtful  if  any  anti- 
septic of  sufficient  strength  to  be  bactericidal  will  not  be  strong 
enough  to  cause  the  irritation  of  the  skin ;  2  per  cent  of  carbolic 
acid  can  be  added  if  there  is  much  itching,  but  it  must  not  be 
used  very  strong. 

Toys  and  books  should  be  destroyed  after  the  child  has  been 
removed  from  quarantine. 

The  room  should  be  carefully  fumigated  and  the  walls  and 
woodwork  wiped  down  with  a  1 :1000  solution  of  bichloride  of 
mercury  or  1 :20  solution  of  carbolic  acid. 

Symptomatic  Treatment. — As  there  is  no  specific  for  scarlet 
fever  the  treatment  is  largely  symptomatic. 

Fever. — For  hj'perpyrexia  coal-tar  products  should  not  be 
used  but  hydrotherapy  employed  without  any  hesitation.  The 
sponge  bath  or  wet-sheet  pack  can  be  used  without  trouble,  and 
in  spite  of  remonstrance  from  the  family.  During  the  bath 
at  a  temperature  of  85°  F.  or  90°  F.,  the  circulation  should  be 
watched,  especially  of  the  hands  and  feet,  and  liot-water  bags 
applied  to  them  if  they  are  persistently  cold.  A  continuous 
temperature  of  103.5°  F.  usually  requires  attention,  but  the 
effect  of  the  temperature  on  the  patient  should  be  the  guide. 
Gentle  friction  of  the  skin  should  be  used  wliile  the  bath  is  being 
given.  A  little  alcohol  in  the  water  for  sponge  bath  is  ad- 
vantageous. It  is  well,  with  a  tendency  for  the  temperature 
to  run  high,  to  place  an  ice  bag  to  the  head,  which  usually 
materially  assists  in  the  control  of  the  fever. 

Kidneys. — Water  should  be  given  at  very  frequent  intervals 
from  the  onset  of  the  symptoms  in  order  to  keep  the  kidneys 
flushed.  This  is  especially  so  in  the  cases  with  severe  angina 
when  the  mixed  infection  is  apt  to  be  a  feature.  The  following 
is  of  benefit : 

IJ  Liq.  ammonii  acetatis        353 
Spiritus  aetheris  comp.       5! 
Aquae    destillat.  q.  s.  Jiv 

M.     Sig.     One  teaspoonful  every  3  hours. 


CONTAGIOUS  DISEASES.  387 

Bowels. — If  the  vomiting  is  not  persistent,  an  initial  dose  of 
calomel  of  1  to  3  grains  is  of  great  benefit  and  should  be  given 
as  soon  as  possible.  If  not  effectual  in  obtaining  a  free  evacua- 
tion it  should  be  followed  by  2  or  3  drachms  of  castor  oil.  Daily 
evacuations,  which  must  be  insisted  upon,  can  probably  be  ob- 
tained by  using  an  enema  or  glycerine  suppository.  An  occa- 
sional drachm-dose  of  cascara  aromatic,  or  syrup  of  tamarinds 
or  milk  of  magnesia  may  be  needed  during  the  bed  stage. 

Owing  to  the  great  amount  of  extra  work  thrown  upon  the 
kidneys,  the  diet  should  be  such  as  will  not  increase  elimination 
by  the  kidnej's,  hence  a  milk  diet  is  decidedly  the  best.  A  mixed 
diet,  wath  no  meat,  can  be  begun  after  complete  subsidence  of 
the  fever  and  rash. 

A  very  good  rule  to  follow  is  to  keep  the  child  in  bed  for  one 
week  after  the  disappearance  of  the  rash,  and  then  to  let  it  get 
out  of  bed  for  a  gradually  increasing  time  each  day,  being  well 
protected  from  exposure  if  not  entirely  dressed. 

Nose,  Throat  and  Ears. — Antiseptic  spray,  Dobell's  solution, 
normal  salt  and  boracic  acid  solution  in  equal  parts,  w^armed 
to  110°  F.,  can  be  used  as  either  a  spray,  douche  or  snuffed  up 
the  nose,  in  cases  with  profuse  nasal  discharge,  or  used  as  an 
irrigation  in  angina.  The  danger  of  forcing  fluids  through  the 
Eustachian  tube  into  the  middle  ear  and  causing  an  infection 
should  be  remembered.  Nasal  irrigation  with  fountain  syringe 
is  recommended  in  smaller  children. 

Regular,  four-hour  interval  irrigation  of  the  middle  ear  when 
the  drum  has  ruptured  with  warm  boracic  acid  solution  should 
be  carefully  done,  the  ear  dried,  and  powdered  boracic  acid 
insufflated  into  the  middle  ear.  Paracentesis  of  the  drum  should 
be  done  if  an  examination  of  it  shows  it  to  be  bulging,  in  order 
to  obtain  free  and  prompt  drainage.  This  should  be  done  under 
a  general  anesthetic  always,  as  the  shock  to  the  child  from  the 
pain  and  being  held  is  too  great  to  have  it  done  without.  Gas 
anesthesia  is  quick  and  safe  and  is  recommended. 

Soreness  of  the  throat  is  a  prominent  symptom  at  the  onset, 
and  cold  applications  are  very  serviceable.  A  small,  wet  flannel 
is  folded  and  placed  next  the  throat  and  covered  with  a  wider, 
dry  piece  of  goods.     Crushed  ice  fed  to  the  patient  is  sometimes 


388  THE   DISEASES   OP    CHILDREN. 

found  to  be  grateful  to  the  throat.     The  tendency  to  adenitis 
may  be  largely  controlled  by  the  cold,  wet  pack. 

For  the  nervousness  and  restlessness  which  is  often  a  decided 
feature  in  the  early  stages  of  the  eruption,  the  following  can 
be  safely  used  in  a  child  of  five  years : 

IJ  Strontii  broraidi  3iii 

Chloralis  5i8S 

Syr.  limonis  5^ 

Aquae  destillat.  q.  s.  ^ui 

M.  ft.  sol. 
Sig.     One  teaspoonful  every  3  hours  as  needed. 

Heart. — The  circulation  should  be  watched  closely.  The  ten- 
dency is  to  have  a  much-increased  pulse  rate  and  the  first  evi- 
dence of  flagging  in  its  quality  should  be  met  by  the  adminis- 
tration of  strychnia,  whisky  and  probably  by  digitalis.  Digitalis 
can  be  given  in  the  fat-free  tincture,  in  5  drop  doses.  If  whisky 
is  used,  only  an  article  of  known  value,  or  one  which  has  been 
bottled  in  bond,  should  be  used.  Strychnia  can  be  given  in 
1/150  grain  doses,  and  if  used  for  some  time  the  child  watched 
carefully  for  twitchings  which  may  develop  if  it  is  used  too  long. 

During  convalescence  iron  is  indicated  in  some  form,  and  if 
there  is  an  indication  of  kidney  involvement,  Basham's  mixture 
is  serviceable,  in  %  to  1  teaspoonful  doses,  well  diluted,  three 
or  four  times  a  day. 

Severe  adenitis  is  best  treated  by  the  application  of  ice 
cloths  or  an  ice  bag.  No  virtue  can  be  found  in  the  so-called 
mud  preparations,  and  only  great  discomfort  is  given  the  patient 
when  they  are  applied. 

Too  much  emphasis  cannot  be  laid  upon  the  importance  of 
fresh  air  throughout  the  entire  course  of  the  disease.  Protect 
the  bed  from  draughts,  plenty  of  coverings,  and  keep  the  win- 
dows open,  an  open  fireplace  is  to  be  preferred  greatly  to  a 
gas  fire,  closed  stove  or  furnace  heat. 

The  serum  treatment  has  been  recommended,  antistreptococcic 
serum  as  a  routine  and  the  antidiphtheritie  serum  in  the  true 
diphtheritic  anginal  cases. 


CONTAGIOUS  DISEASES.  389 

VARICELLA. 

Synonym. — Chicken-pox. 

Definition. — A  specific,  infectious  and  contagious  eruptive 
disease  common  to  childhood.  It  is  characterized  by  a  rash 
which  appears  as  a  maculopapule,  followed  by  a  vesicle,  the 
latter  drying  and  falling  off  as  an  encrustation  or  scab. 

Etiology. — The  specific  organism  has  not  been  isolated,  but 
it  is  highly  contagious  and  can  be  carried  by  a  third  person. 
It  is  contagious  throughout  the  eruptive  stage,  the  scales  being 
capable  of  transmitting  it.  Age  is  an  important  factor.  It 
occurs  chiefly  in  children  under  10  years  of  age,  being  rarely 
seen  in  adults.  It  has  no  relation  to  small-pox  and  one  does  not 
protect  from  the  other. 

Symptoms. — ^Period  of  incubation,  invasion  or  prodrome, 
eruption  and  desquamation. 

The  incubation  period  is  from  10  to  16  days,  the  average  pe- 
riod being  about  12  days.  There  are  no  symptoms  common  to 
this  period. 

Invasion. — There  are  few  prodromal  symptoms,  in  the  major- 
ity of  cases  the  rash  being  the  first  symptom.  Frequently  the 
child  may  be  quite  restless  during  the  night  and  may  itself 
call  attention  to  the  rash  when  dressing  in  the  morning.  There 
is  apt  to  be  a  slight  rise  in  temperature.  Digestive  disturbances 
are  rare,  though  there  may  be  vomiting. 

Eruption. — The  first  spots  noticed  are  usually  upon  the 
chest,  and  the  margin  of  the  hair  and  face.  If  seen  early  the 
rash  will  appear  as  a  reddish  blotch,  followed  soon  by  a  papule, 
upon  the  apex  of  this  appearing  a  tiny  vesicle  which  gradually 
enlarges  in  size.  The  rash  rapidly  spreads  to  other  parts  of  the 
body,  appearing  in  successive  crops  for  48  hours,  so  that  at  the 
end  of  this  period  there  are  present  all  stages  of  the  eruption 
at  the  same  time.  The  papule  usually  is  about  one-fourth  of 
an  inch  in  diameter,  the  vesicle  being  slightly  smaller,  having 
the  appearance  of  resting  upon  a  red  base.  Occasionally  the 
vesicle  will  develop  upon  the  skin  without  the  primary  macule 
or  papule,  looking  like  a  drop  of  water  on  the  skin.  The  fluid 
of  the  vesicle  at  first  is  clear,  but  in  a  few  hours  it  is  cloudy  in 
color.     The  vesicle  is  unilocular  and  when  pricked  upon  the  top 


390  THE  DISEASES  OP   CHILDREN. 

the  fluid  escapes.  Infrequently  the  vesicles  are  unbilicated,  in 
this  respect  resembling  the  small-pox  vesicle.  As  the  vesicle 
dries  the  scab  forms.  Sometimes  the  vesicle  becomes  infected 
and  a  good  deal  of  cellular  infiltration  may  occur,  with  ulcera- 
tion into  the  true  skin,  and  resulting  pitting  scar.  Coincident 
with  the  appearance  of  the  exanthem,  the  enanthem  appears  on 
the  mucous  surfaces,  the  mouth,  vulva  and  prepuce. 

The  eruptive  stage  lasts  from  three  to  four  days,  when  all 
the  spots  are  usually  scabbed  over,  the  scabs  becoming  separated 
in  from  two  to  three  weeks. 

Systemic  Symptoms. — The  temperature  rises,  though  it  is  ex- 
ceptional to  find  it  very  high.  It  does  not  run  a  regular  course, 
and  is  rarely  over  102.5°  to  103°  F.  During  the  fever  the 
papular  and  vesicular  stages,  the  child  is  restless  and  peevish, 
complains  frequently  of  itching  and  burning,  and  the  tempta- 
tion to  scratch  is  very  great.  No  digestive  disturbances  are 
seen,  as  a  rule,  unless  there  is  the  initial  vomiting,  which  does 
not  recur. 

Desquamation  slowly  proceeds  during  the  last  two  weeks  of 
the  disease,  a  few  scales  dropping  off  from  day  to  day,  usually 
leaving  a  dry  base,  lighter  in  color  than  the  surrounding  skin. 
Sometimes  there  is  a  decided  ulceration,  in  case  the  vesicle 
has  been  infected. 

Complications  and  Sequelae. — The  only  complication  of  mo- 
ment I  have  ever  seen  was  an  erysipelas,  which  was  verj^  severe 
and  extensive,  and  which  proved  fatal. 

Varicella  gangrenosa  has  been  reported  as  a  complication. 
This  is  extremely  severe  and  usually  fatal.  Ulceration  at  the 
site  of  one  or  more  of  the  vesicles  may  take  place,  extending  into 
the  true  skin,  and  these  always  leave  a  pitting  scar.  It  is  quite 
usual  to  find  one  or  more  of  these  pits  somewhere  upon  the  body. 

Hemorrhage  may  rarely  occur  in  the  vesicles.  Second  at- 
tacks are  practically  never  seen. 

True  nephritis  may  be  a  complication,  albumen  is  frequently 
temporarily  present. 

Diagnosis. — The  chief  disease  to  be  diagnased  from  is  small- 
pox of  a  mild  type.  Corlett  gives  the  following  diagnostic 
points:     (a)     Varicella    has    mild    prodromal    symptoms,    and 


CONTAGIOUS  DISEASES.  391 

they  may  be  absent  altogether.  (6)  The  eruption  appears  on 
the  trunk,  where  it  is  more  abundant  than  on  the  face  and 
hands,  (c)  The  multiform  character  of  the  eruption,  its  super- 
ficial position,  comparable  to  drops  of  water  sprinkled  over  the 
skin,  and  its  appearance  on  the  same  region  in  successive  crops. 
(d)  Its  mild  constitutional  symptoms  and  short  duration,  the 
disease  usually  terminating  in  5  to  14  days,  (e)  It  is  mildly 
infectious  and  always  gives  rise  to  the  same  disease. 

Prognosis. — In  uncomplicated  cases  is  always  good. 

Treatment. — Isolation  is  the  principal  consideration.  Atten- 
tion to  the  bowels  is  very  necessary  with  an  initial  dose  of 
calomel.  A  simple  diet  should  be  given,  preferably  only  liquid 
or  soft  food,  according  to  the  age  of  the  child.  Confinement 
to  bed  is  necessary  only  during  the  febrile  stage.  If  the  child 
is  old  enough  it  should  be  warned  against  scratching,  if  too 
young  its  hands  should  be  covered  in  order  to  prevent  it.  A 
2  per  cent  carbolic  acid  vaseline  ointment  will  prevent  itching 
and  make  the  patient  more  comfortable.  The  bowels  and  diges- 
tion must  be  watched  and  daily  baths  given. 

VACCINATION. 

Synonym. — Cowpox. 

Definition. — This  is  an  eruptive  disease  in  the  human  raxje 
caused  by  the  introduction  into  the  system  of  the  small-pox 
virus  or  lymph,  obtained  from  one  of  the  vesicles. 

History. — Edw.  Jenner,  in  May,  1796,  ^ter  observation  of 
cases  of  cowpox  in  milkers  and  the  immunity  it  gave  those  con- 
tracting it,  performed  the  first  vaccination  on  the  human  subject. 
The  first  vaccination  in  America  was  performed  in  1800  in 
Cambridge,  ]\Iass.  Statistics  prove  what  a  boon  to  humanity 
has  been  the  discovery  of  vaccination. 

Technic. — A  child  should  be  vaccinated  before  the  end  of  its 
first  year,  and  revaccinated  at  the  end  of  every  seven  years. 
Statistics  have  shown  that  in  cases  of  small-pox  occurring  in 
persons  giving  a  history  of  a  successful  vaccination,  the  vac- 
cination Avas  usually  done  more  than  seven  years  previously. 

Vaccination  should  not  be  done  in  a  child  who  is  acutely  ill 
or  who  has  a  skin  lesion,  or  in  a  child  suffering  from  any  of  the 


392  THE   DISEASES   OF    CHILDREN. 

diseases  of  malnutrition.  The  occurrence  of  an  epidemic  of 
small-pox  is  the  only  reason  for  not  making  these  exceptions. 

The  site  of  the  vaccination  has  been  the  subject  of  much 
comment,  whether  it  should  be  done  upon  the  leg  or  the  arm. 
Owing  to  the  possibility  of  an  infection  occurring  after  the 
operation  and  the  greater  number  and  size  of  the  inguinal 
lymphatics,  the  choice  of  the  arm  should  always  be  made.  The 
point  of  selection  is  just  above  the  insertion  of  the  deltoid 
muscle  upon  the  arm  least  used,  the  left  arm  in  the  right  handed, 
and  vice  versa. 

The  selection  of  the  virus  should  be  made  with  care :  The  scab 
from  a  human  vaccination  scar  should  never  be  used  because  of 
the  danger  of  infection.  Only  bovine  lymph  should  be  em- 
ployed and  the  glycerinated  lymph  is  best,  as  this  form  of 
lymph  is  sterile  and  there  is  no  chance  for  it  to  become  con- 
taminated with  bacteria.  The  glycerinated  lymph  is  furnished 
by  reliable  firms  in  sealed  capillary  tubes  and  in  hermetically- 
sealed  tubes  containing  glass  or  ivory  points,  upon  which  is 
smeared  the  virus. 

The  operation  should  be  considered  strictly  a  surgical  pro- 
cedure and  performed  with  great  care  and  in  a  surgically, 
cleanly  manner.  The  arm  is  bared,  washed  with  soap  and  water, 
and  dried,  but  no  antiseptics  should  be  used.  The  skin  should 
be  scarified  over  an  area  one-half  inch  square,  and  the  lymph 
rubbed  into  this  and  allowed  to  dry.  A  sterile,  medium-size, 
cambric  needle  can  be  used  for  the  scarification,  care  being 
taken  not  to  make  the  scratch  deep  enough  to  draw  blood,  or 
the  end  of  the  point  can  be  used  to  rub  off  the  upper  skin.  It 
usually  takes  15  or  20  minutes  for  the  lymph  to  dry.  To  facil- 
itate the  child's  having  its  sleeve  pulled  down,  cut  a  piece  of 
light  cardboard,  round,  li/^  to  2  inches  in  diameter,  and  then  cut 
it  half  through.  The  cut  edges  are  slipped  by  each  other  and 
a  cone  formed.  This  is  held  in  place  by  narrow  strips  of  ad- 
hesive plaster.  "When  the  lymph  is  dry  the  improvised  cone 
shield  can  be  removed. 

The  after-care  of  the  vaccination  area  should  be  mentioned. 
Bad  results  are  due  to  infection  transmitted  to  the  wound  after 
the  vaccination  has  been  performed,  and  not  to  contaminated 


CONTAGIOUS   DISEASES.  393 

virus,  provided  the  virus  from  a  reliable  maker  has  been  selected. 
After  the  wound  has  dried  it  usually  needs  no  attention  or  pro- 
tective dressing,  unless  it  be  one  or  two  layers  of  gauze  bandage. 
A  typical  vaccination  will  run  its  course  without  breaking 
down  or  becoming  moist.  If  it  does  become  moist  and  the 
sleeve  sticks  to  it  a  shield  which  is  perforated,  has  a  wide  base 
to  rest  upon  the  arm,  and  large  enough  to  make  no  pressure  on 
the  vesicle,  should  be  applied  as  a  protection.  If  the  wound 
becomes  infected  with  pus  formation  it  should  be  treated  sur- 
gically as  other  wounds. 

Normal  Course. — Upon  the  third  or  fourth  day  following  a 
successful  vaccination,  the  area  scarified  becomes  red,  and  slightly 
indurated  and  raised.  Upon  this  area,  on  the  next  or  second 
day  following,  a  vesicle  forms,  slightly  smaller  than  the  red  area, 
which  is  decidedly  umbilicated.  The  reddened  area  spreads  to 
half  an  inch  or  more  in  width,  wdth  perhaps  a  congested  area, 
much  lighter  in  color,  extending  2  or  3  inches  or  encircling 
the  entire  arm.  The  vesicle  at  first  is  pearly  white,  gradually 
changing  in  color  to  a  yellow  or  brownish  color,  and  then  dry- 
ing up,  if  normal,  without  rupture.  A  distinct  scab  forms 
which  gradually  loosens,  leaving  a  dry  scar,  slightly  depressed, 
and  containing  a  number  of  smaller  depressions  or  pits. 

The  time  usually  required  for  a  "take"  is  as  follows:  Fourth 
day,  indurated  red  area  or  papule;  sixth  day,  vesicle;  tenth 
day,  pustule;  twelfth  day,  scab;  fifteenth  to  eighteenth  day, 
scab  separates,  leaving  the  scar. 

Symptoms. — Coincident  with  the  formation  of  the  vesicle  there 
may  be  a  rise  of  temperature  from  3°  to  5°,  101°  to  103°  F., 
and  may  last  until  the  formation  of  the  scab.  The  arm  feels 
swollen  and  stiff,  and  there  may  be  some  glandular  enlargement 
in  the  axilla,  and  pain.  Around  the  vaccination  area  several 
small  pustules  may  form  which  are  superficial  and  leave  no 
scars. 

Complications. — The  chief  complications  which  occur  are  those 
referable  to  the  skin,  and  the  most  striking  is  a  general  vaccinia. 

This  is  an  eruption  which  is  like  that  seen  in  some  cases  (and 
referred  to  above)  occurring  around  the  site  of  the  vaccination, 
pustular  in  character,  appearing  about  the  tenth  day,  and  if 


394  THE  DISEASES  OF    CHILDREN. 

closely  watched   passing  through   the   papular,   vesicular   and 
pustular  stages. 

A  general  erythematous  eruption  is  n^ore  frequently  seen, 
resembling  a  measles  eruption.  This  may  occur  only  on  the 
trunk  or  around  the  waist,  buttocks  and  thighs.  It  is  hot, 
slightly  raised  and  itches  a  good  deal,  and  usually  is  of  short 
duration,  lasting  from  a  few  hours  to  two  or  three  days. 

An  urticaria,  similar  to  that  complicating  the  injecting  of 
any  of  the  sera  subcutaneously,  may  occur. 

A  cellulitis  about  the  vaccination  area  is  a  common  occur- 
rence. The  entire  arm  may  be  involved,  it  is  greatly  swollen, 
very  tense  and  painful,  the  arm  is  very  "sore."  In  these  cases 
the  vesicle  is  apt  to  rupture,  and  the  whole  area  occupied  by  the 
vesicle  may  become  gangrenous. 

In  the  colored  race,  especially,  and  frequently  in  the  'white, 
a  keloid  forms  in  the  scar  tissues  left  after  the  separation  of 
the  scab,  which  may  become  raised  above  the  surface  of  the 
skin,  and  is  firm  and  glazed. 

An  adenitis  sometimes  develops,  in  the  axilla  or  groin,  the 
glands  being  enlarged  and  tender  during  the  inflammatory 
stage  of  the  "take." 

The  distinctness  of  the  vaccination  scar  is  not  sufficient  evi- 
dence of  the  persistence  of  immunity  conferred  by  a  single  vac- 
cination. It  is  frequently  found  that  a  typical  "take"  is  re- 
corded in  a  person  with  an  excellent  and  typical  mark  if  more 
than  seven  years  have  elapsed  since  the  first  vaccination. 

A  natural  immunity  does  not  exist.  If  a  primary  "take" 
has  not  been  obtained  there  has  been  some  fault  in  the  technic, 
and  the  operation  should  be  repeated  until  successful.  I  have 
revaecinated  myself  until  on  the  fifth  attempt  a  successful 
"take"  was  obtained. 

VARIOLA. 

Synonym. — Small-pox. 

Definition. — The  most  contagious  of  the  exanthemata  char- 
acterized by  a  sudden  onset,  high  fever,  a  rash,  going  through 
regular  stages  of  development,  viz.,  papule,  vesicle,  pustule,  scab, 
desquamation  and  cicatrices.  If  one  unprotected  by  vaccina- 
tion is  exposed  to  the  contagion  he  is  practically  always  attacked. 


CONTAGIOUS  DISEASES.  395 

Etiology. — It  is  believed  by  Councilman  and  others  that  the 
organism,  the  cause  of  small-pox,  has  been  isolated,  though  it 
has  not  been  cultivated  on  artificial  media.  These  bodies  are 
described  as  occurring  ''in  epithelial  cells,  in  the  nuclei  and 
free." 

The  disease  in  contracted  by  direct  contact  and  the  contagion 
can  be  carried  upon  the  clothing,  etc.  The  most  virulent  car- 
rying medium  is  the  pus  from  the  pustules,  and  the  scabs  which 
later  form,  and  the  excreta.  The  organism  gains  entrance  to 
the  body  through  the  mucous  membrane.  The  contagion  can  be 
carried  through  the  medium  of  the  air.  It  is  contagious  from 
the  first  symptom  until  desquamation  is  complete. 

Segregation  in  cold  weather  increases  the  frequency  of  small- 
pox. 

Symptoms. — Several  types  are  recognized,  variola  vera,  which 
may  be  continent  or  discrete;  hemorrhagic;  varioloid  or  modified 
form. 

The  ordinary  form  has  the  following  periods,  invasion,  incu- 
bation, eruption  and  desquamation. 

Invasion. — According  to  different  observers  the  stage  of  inva- 
sion lasts  from  8  to  20  days,  the  average  being  probably  15  days. 
There  are  no  symptoms  to  this  stage. 

Incubation. — The  symptoms  of  this  stage  vary  according  to 
the  age  of  the  patient.  In  the  young  it  is  frequently  ushered 
in  by  a  convulsion,  nausea  and  vomiting.  In  the  adult,  there 
may  be  a  chill,  instead  of  the  convulsion.  There  is  regularly 
a  rapid  rise  in  temperature,  usually  reaching  104°  F.,  without 
much  variation,  severe  headac^je  and  pain  in  the  back  in  the 
region  of  the  loins.  This  pain  is  perhaps  the  most  prominent 
symptom.  The  bowels  may  be  disturbed,  but  not  regularly 
so.     The  pulse  is  consistently  rapid. 

Eruption. — On  the  third  day,  sometimes  on  the  second,  a 
macular  eruption  appears  on  the  forehead,  at  the  margin  of  the 
hair  particularly,  face,  wrists  and  forearms,  and  neck,  which  by 
the  fourth  day  is  decidedly  papular.  The  papules  soon  appear 
on  the  extremities,  palms  and  soles,  and  in  less  numbers  on  the 
body.  These  have  a  distinct  shottj'  feel.  The  first  day  they  may 
be  difficult  to  diagnose.     It  quickly  spreads  to  the  rest  of  the 


396  THE   DISEASES   OP    CHILDREN. 

body.  On  the  summit  of  the  papules  vesicles  form  about  the 
fifth  day,  which  gradually  change  to  pustules  by  the  tenth  day, 
and  by  the  fourteenth  day  these  have  become  encrusted,  with  a 
shedding  of  some  of  the  crusts.  The  desquamation  proceeds  in 
the  order  of  the  appearance  of  the  rash. 

An  enanthem  forms  coincidently  with  the  exanthem. 

The  vesicles  have  a  decided  umbilication  or  depression,  which 
remain  until  the  pustules  form.  If  pricked  these  vesicles  do  not 
collapse  because  of  the  reticular  division  inside  them.  After 
the  scabs  fall  off  the  skin  is  left  slightly  discolored,  and  according 
to  the  depth  of  the  ulceration  a  pit  or  depressed  scar  remains. 
There  may  be  a  coalescence  of  the  pustules  on  the  face,  or  they 
may  rupture,  the  pus  drying  upon  the  skin  forming  a  crust 
over  the  entire  face. 

The  fever  runs  a  fairly  typical  course,  sudden  of  onset,  reach- 
ing 104°  or  even  106°  F.  the  first  day,  and  remaining  up  until 
the  eruption  appears,  when  it  gradually  recedes  to  normal  or 
very  slightly  above,  about  the  fifth  day.  It  remains  down  then 
until  the  pustules  are  formed,  about  the  tenth  day,  when  it 
reaches  usually  the  height  it  was  at  first,  or  even  higher.  This 
is  the  secondary  fever.  Fever  persists  during  the  pustular 
stage,  gradually  falling;  symptoms  abate,  the  restlessness,  back- 
ache, headache,  etc.,  improve. 

During  the  septic  temperature  there  is  a  return  of  these  symp- 
toms to  a  certain  extent,  and  they  may  be  very  severe.  Absorp- 
tion may  be  enough  to  cause  septic  symptoms  of  gravity,  the 
patient  being  drowsy  or  even  delirious. 

In  the  confluent  variety,  in  wljich  there  is  a  coalescence  of  the 
vesicles  and  pustules,  all  of  the  symptoms  are  more  severe. 

Hemorrhagic  Variola.  This  form  is  the  most  severe.  There 
is  an  extravasation  of  blood  in  the  vesicles,  either  as  a  primary 
lesion  or  the  blood  appearing  during  the  pustular  stage. 

Varioloid.  This  is  a  modified  form  of  small-pox  occurring  in 
individuals  in  whom  the  immunity  from  a  previous  vaccination 
has  about  disappeared,  and  is  as  contagious  as  variola,  a  severe 
true  small-pox  may  be  caused  by  it.  In  varioloid  there  is  very 
little  eruption  and  no  secondary  fever,  all  of  the  symptoms  being 
very  much  less  severe,  and  of  shorter  duration. 


CONTAGIOUS  DISEASES.  397 

Complications. — These  are  few,  as  a  rule.  The  pustules  may 
cause  deep  ulceration  and  consequent  pitting  and  permanent 
scarring  of  the  skin. 

There  may  be  a  catarrhal  or  purulent  inflammation  of  the 
middle  ear.  The  eyes  may  be  involved,  an  ulceration  of  the 
cornea  being  sometimes  found.  A  laryngitis  is  not  infrequent, 
and  an  extension  downward  causing  a  bronchopneumonia  or 
edema  of  the  pharynx  and  larynx  may  occur.  Fiirimculosis 
and  adenitis  occasionally  occur  during  the  convalescence.  Ar- 
thritis may  complicate  the  disease. 

Diagnosis. — Until  the  appearance  of  the  rash  the  diagnosis 
cannot  be  positively  made,  but  when  a  sudden  high  temperature 
is  seen  with  severe  headache  and  backache,  in  the  absence  of  an 
epidemic  of  grippe,  small-pox  should  be  suspected.  The  most 
frequent  disease  with  which  it  is  confused  is  chicken-pox.  The 
great  infrequency  of  chicken-pox  occurring  in  adults  should 
cause  variola  to  be  suspected  in  every  vesicular  eruption.  The 
discrete  eruption  in  varioloid  and  the  mildness  of  the  general 
symptoms  are  deceptive. 

Prognosis. — Vaccination  and  age  influence  the  prognosis 
greatly.  The  mortality  in  late  epidemics  has  been  very  light. 
In  the  unvaccinated  young  the  prognosis  is  always  grave.  The 
extent  of  the  rash  upon  the  face  is  a  good  guide  as  to  the 
severity  of  the  attack.  The  hemorrhagic  form  is  very  fatal. 
The  occurrence  of  any  of  the  complications  makes  the  prognosis 
less  favorable. 

Treatment. — Prophylaxis. — ^Vaccination,  isolation  and  disin- 
fection are  the  best  methods  of  prevention.  It  is  absolute  by 
vaccination,  the  immunity  thus  conveyed  lasting  in  its  fullest 
from  five  to  seven  years.     Revaccination  should  be  practiced. 

No  city  is  safe  from  epidemics  without  the  erection  of  an 
isolation  hospital,  removed  beyond  the  city  limits.  The  care 
of  these  cases  should  be  left  to  the  city  authorities,  and  prompt 
report  of  cases  in  the  city  made  to  the  Health  Board  should  be 
required. 

Disinfection  should  be  most  thorough,  the  formaldehyde,  per- 
manganate of  potash  method  being  very  efficient.  Bedding 
should  be  destroyed  and  the  room  thoroughly  overhauled  and 


398  THE  DISEASES  OP   CHILDREN. 

cleaned.  Vaccination  of  every  person  known  to  have  been  ex- 
posed to  a  case  of  small-pox  should  be  insisted  upon,  and  its 
spread  thus  limited  or  stopped  entirely. 

Local. — The  confinement  of  the  patient  in  a  room  in  which 
only  red  rays  of  light  are  admitted  has  been  shown  to  be 
efficient  in  limiting  the  inflammatory  reaction  in  the  pustules, 
and  consequent  limiting  of  the  amount  of  pitting  or  scarring. 

The  pain  and  burning  in  the  skin  from  the  eruption  is  best 
relieved  by  the  local  application-  of  soothing,  antiseptic  lotions 
upon  a  mask  cut  from  gauze.     The  following  is  of  benefit: 

IJ  Acidi  carbolici  puri  liquefacti  3is3 

Zinci  oxidi  pulv.  3i 

Aquae  destillatae  q.  s.   "^vr 

M.  ft.  sol. 
Sig.     Saturate  cloths  and  apply  to  face  or  other  parts, 

at  frequent  intervals. 

or 

IJ  Ichthj'ol  ammon.  sulph.  3vi 

Aquae  destillat.  "^-v 

M.  ft.  sol. 
Sig:     Locally. 

In  the  pustular  stage  the  following  is  recommended : 

]^  Acidi  carbolici  1Tl,xv 

Aq.  calcis 

01.  Olivae  aa  ^ss 

M.     Sig.     Locally. 

In  the  event  of  eye  involvement,  pus  exuding  from  the  con- 
junctival sac,  and  danger  to  the  cornea  from  ulceration  being 
present,  they  should  be  frequently  irrigated  with  a  5  per  cent 
boracic  acid  solution,  and  an  occasional  drop  of  atropia  solution 
introduced.  Five  per  cent  argj-rol  solution  will  be  of  benefit  in 
the  purulent  condition  sometimes  seen. 

Fever  is  best  combated,  both  primary  and  secondary,  by 
hydrotherapy,  sponge  bath,  wet  pack  or  tub  bath.  The  use  of 
baths  during  desquamation,  followed  by  oil  rubs,  hastens  this 
stage.  The  patient  should  be  kept  strictly  in  bed  during  the 
entire  eruptive  stage. 

For  the  great  pain  in  the  back  and  head  during  the  stage  of 


CONTAGIOUS  DISEASES.  399 

incubation,  an  opiate  may  be  necessary.  The  coal-tar  deriva- 
tives should  be  used  with  great  caution. 

Stimulation  may  be  needed  at  certain  stages,  whisky,  digitalis 
or  strychnia. 

The  diet  should  be  fluid,  preferably  milk,  and  broths  with 
plenty  of  water. 

Bromide  and  chloral  can  be  used  for  the  great  restlessness. 

PERTUSSIS. 

Synonym. — WJwoping-cough. 

Etiology .^The  organism  which  is  now  believed  to  be  the  spe- 
cific cause  of  pertussis,  was  discovered  by  Bordet,  working  in 
collaboration  with  Gengou,  in  1905,  and  is  a  small  eoccibacillus 
resembling  the  bacillus  of  influenza  in  size  and  shape.  It  is 
usually  found  in  the  viscid  exudate  expectorated  from  depth  of 
bronchi  during  paroxysms  of  coughing.  The  organism  may  be 
stained  with  weak  solutions  of  fuchsin  and  does  not  take  the 
Gram  stain.  It  grows  best  in  a  media  made  of  equal  parts  of 
defibrinated  blood  (human  or  rabbit)  and  3  per  cent  agar  con- 
taining small  quantity  of  potato  extract  and  glycerine.  It  also 
grows  fairly  well  on  serum  bouillon  or  blood  bouillon,  but  on 
ordinary  culture  media  only  after  it  has  been  cultivated  in  the 
laboratory  for  some  time. 

AVhile  not  universally  recognized,  the  identity  of  Bordet 's 
bacillus  as  a  causative  factor  of  whooping  cough  is  fairly  well 
established.  The  strongest  evidence  which  we  have  is  perhaps 
the  agglutination  and  complement  fixation  reactions  first  ob- 
served by  Bordet  and  afterwards  confirmed  by  numerous  in- 
vestigators. Further  evidence  is  aiforded  by  an  experiment  of 
Bordet  with  vaccines  prepared  from  this  organism.  Twenty 
children  who  had  been  exposed  to  whooping-cough  were  given 
prophylactic  injections  and  in  every  case  developed  unusually 
violent  cases,  clearly  indicating  that  a  profound  negative  phase 
had  been  produced.  Experiments  on  lower  animals  to  determine 
the  pathogenesis  of  this  organism  have  been  unsatisfactory. 
Ordinary  laboratory  animals  are  not  infected  by  inoculations, 
but  Kliraenco  and  Fraenkel  claim  to  have  produced  typical 
whooping-cough   in   monkeys   by   injections    of   this   organism 


400  THE   DISEASES   OF    CHILDREN. 

Klimenco  also  believes  that  similar  results  were  produced  in 
puppies,  but  this  latter  work  has  been  greatly  questioned. 

Although  inoculations  with  small  quantities  of  this  organism 
into  animals  are  not  followed  by  the  development  of  an  infective 
process,  larger  doses  kill  animals  with  symptoms  of  profound 
toxemia,  evidently  due  to  toxins  generated  during  growth  on 
media.  Toxins  extracted  from  cultures  of  this  organism  in- 
jected into  peritoneum  of  guinea-pig  produce  hemorrhagic  and 
exudative  lesions.  Injected  subcutaneously  they  result  in  edema 
and  necrosis.  Inoculated  into  the  eye  of  a  rabbit  they  produce 
necrosis  of  the  cornea.  Bordet  calls  attention  to  the  fact  that 
an  analogous  necrosing  influence  may  be  observed  on  the  surface 
of  bronchi  of  affected  children  and  believes  that  the  manifesta- 
tions of  this  disease  are  due  to  lesions  of  the  cellular  lining  of 
the  bronchi,  resulting  from  the  action  of  this  irritant  poison. 
This  coincides  with  the  clinical  fact  ' '  that  whooping-cough  ceases 
to  be  a  part  of  the  clinical  picture  immediately  previous  to 
convalescence  at  which  time  germs  become  rare  in  the  exudate. ' ' 

Its  habitat  is  the  nose  and  throat,  and  is  directly  transmitted 
from  one  child  to  another.  It  is  not  necessary  for  the  infecting 
child  to  cough  to  transmit  the  infection,  as  it  can  be  carried 
through  the  air  from  ordinary  breathing,  but  the  children  must 
be  fairly  close  together,  and  also  by  toys,  clothing,  etc.  It  is 
both  endemic  and  epidemic.  It  is  contagious  at  any  time  in  its 
course.  No  age  is  exempt,  though  it  is  much  more  common 
between  the  ages  of  one  and  ten  years,  the  majority  of  cases 
occur  under  three  years  old.  The  youngest  child  I  have  seen 
with  it  was  six  weeks  old,  the  attack  proving  fatal.  Cases  much 
younger  have  been  reported.  One  attack  does  not  confer  im- 
munity in  every  case.  My  oldest  child  had  two  distinct  attacks. 
I  have  seen  one  grandfather  over  60  years  of  age  with  a  severe 
attack. 

Pathology. — There  is  a  catarrhal  condition  of  the  mucous 
membrane  of  the  nose,  pharynx  and  larynx,  and  especially  the 
trachea,  with  very  frequent  involvement  of  the  bronchi  as  a 
complication.  In  severe  cases  there  may  be  a  true  or  a  com- 
pensatory emphysema. 

Sjonptoms. — The  inciihation   is   generally   about  two   weeks. 


CONTAGIOUS  DISEASES.  401 

There  is  a  cough  which  shows  no  tendency  to  improve,  and  in 
spite  of  ordinary  remedies  grows  more  persistent,  and  without 
signs  in  the  chest  to  account  for  it.  This  is  usually  described 
as  the  catarrhal  stage,  and  lasts  from  one  to  two  weeks,  followed 
by  the  spasmodic  and  whooping  stage  and  the  stage  of  recession. 
In  the  catarrhal  stage  there  may  be  a  slight  puffing  of  the  lower 
eyelids,  some  loss  of  appetite  and  disinclination  to  play,  as 
exertion  tends  to  increase  the  cough.  During  the  last  of  this 
stage  the  cough  becomes  more  paroxysmal  in  character,  the  child 
going  some  time  between  the  paroxysms  without  coughing. 
The  paroxysms  become  spasmodic,  they  begin  with  a  slight, 
hacking  cough,  which  graduallj^  becomes  more  severe,  and  ends 
in  a  long-drawn,  deep  inspiration  accompanied  by  a  crowing 
sound,  which  is  the  characteristic  "whoop"  from  which  the 
disease  took  its  name.  Once  heard,  there  is  no  mistaking  the 
sound.  The  child  loses  its  breath  for  a  moment  and  gets  very 
red  or  dark  red  in  the  face,  the  eyes  and  nose  run ;  the  child  runs 
to  some  one  or  grasps  a  fixed  object  for  support,  and  with  the  last 
deep  inspiration  and  whoop,  may  vomit  the  contents  of  the  stom- 
ach, and  mucus  from  the  trachea.  After  the  paroxysm  is  over  the 
child  falls  back  exhausted,  its  color  gradually  returns,  and  il^ 
may  shortly  resume  its  play.  If  the  paroxysms  are  repeated 
very  frequently  there  may  be  a  deep  injection  of  the  superficial 
vessels  in  the  conjunctiva  or  a  subconjunctival  hemorrhage. 
Between  the  paroxysms  the  child 's  face  is  puffy  and  bloated  under 
the  eyes,  due  to  lymphatic  stasis.  There  may  be  an  ulcer  under 
the  tongue  in  children  with  lower  teeth. 

Paroxysms  are  brought  on  by  severe  exercise,  eating,  often  a 
drink  of  water,  excitement,  and  usually  recur  every  half  hour 
to  an  hour  in  the  24,  but  there  are  often  many  more  than  this. 
If  a  count  can  be  kept  of  the  number  of  the  paroxysms,  day 
and  night,  the  effect  of  medicinal  treatment  can  best  be  noted, 
as  a  lessened  number  of  paroxysms  would  be  the  first  improve- 
ment. 

After  about  two  weeks,  or  more,  of  the  severe  paroxysms  their 
frequency  and  severity  both  become  less,  and  in  this  period  of 
decline,  the  child  shows  a  general  improvement.  It  does  not 
vomit  now  with  each  paroxysm  and  sleeps  longer  at  night. 


402  THE   DISEASES   OF   CHILDREN, 

During  this  stage,  if  the  child  acquires  a  fresh  "cold,"  its 
cough  partakes  of  the  same  paroxysmal  nature,  and,  in  fact,  for 
some  weeks  afterward. 

Complications. — The  most  frequent  is  a  bronchitis,  though  a 
bronchopneumonia  is  often  seen.  An  emphysema  may  occur  in 
very  severe  cases,  which  is  more  or  less  permanent.  From  the 
passive  congestion,  due  to  bronchial  involvement,  there  are  apt 
to  be  hemorrhages  from  the  nose  and  into  the  conjunctiva  and 
brain.  Hernia  may  result  from  the  straining  at  coughing,  and 
the  rectum  may  also  be  forced  out  in  young  children.  Incon- 
tinence of  urine  during  coughing  is  not  infrequent.  Albumen 
and  casts  may  be  found  in  the  urine  during  the  height  of  the 
attack.  The  simultaneous  occurrence  of  measles  and  pertussis 
has  been  often  reported.  Tuberculosis  may  have  its  starting 
point  in  an  attack  of  pertussis.  Convulsions  may  occur  in  the 
young. 

Diagnosis  is  not  at  all  certain,  and  is  most  often  made  by  the 
mother  and  nurse  before  seen  by  the  physician.  A  history 
of  exposure,  and  paroxysmal  coughing,  even  without  the  whoop, 
is  sufficient  for  a  diagnosis.  In  an  epidemic  one  may  see  severe 
paroxysmal  coughs  and  absolutely  no  tendency  to  whoop.  The 
diagnosis  must  be  made  from  tubercular  bronchial  glands,  hyper- 
trophied  tonsils  and  chronic  bronchitis. 

Churchill  ^  and  others  have  made  investigations  as  to  the 
differential  blood  count  during  whooping-cough.  Comparing 
the  lymphocyte  count  in  whooping-cough  with  a  normal  count 
of  a  child  at  10  years,  which  will  average  32  per  cent,  in  whoop- 
ing-cough it  will  run  from  34  per  cent  to  93  per  cent. 

Mosenthal  ^  found  in  "institutional"  children  the  average 
leucocyte  count  to  be  13,850  to  16,391.  The  percentage  of 
polymorphonuclear  cells  is  slightly  diminished  with  a  corre- 
sponding increase  in  the  mononuclears. 

During  the  catarrhal  stage  of  pertussis,  an  increase  in  leu- 
cocytes is  found,  approximating  double  the  normal,  and  the 
mononuclear  cells  increased  about  5.5  per  cent. 

A  hyperleucocytosis,  with  an  increase  in  the  percentage  of 


^  Journal   American    Medical    Association,    1906,    volume    xlvi,    1506-9. 
''Archives   Pediatrics,   November,   1908. 


CONTAGIOUS   DISEASES.  403 

mononuclear  cells  at  the  expense  of  the  polymorphonuclear,  is 
an  aid  to  the  diagnosis  of  pertussis  in  the  catarrhal  stage. 

Prognosis. — In  very  young  children  the  prognosis  is  always 
grave  because  of  the  lack  of  nourishment,  the  physical  exhaus- 
tion due  to  the  coughing,  the  tendency  to  the  occurrence  of  com- 
plications. Too  little  attention  is  paid  to  whooping-cough,  as  a 
rule,  and  there  are  too  many  wanton  and  willful  exposures  to 
it,  "that  the  child  may  have  it  while  it  is  young,"  for  many  a 
child  dying  of  pneumonia  had  whooping-cough  as  the  chief 
factor  in  the  fatality.  The  more  frequent  the  paroxysms  and 
the  vomiting,  the  graver  the  prognosis.  The  beginning  of  an 
epidemic  in  institutions  is  greatly  to  be  feared.  In  the  1902 
census  whooping-cough  ranked  fourth  as  a  cause  of  death.  In 
1906  it  caused  more  deaths  than  measles  or  scarlet  fever. 

Treatment. — Quarantine  of  the  affected  child  should  always 
be  insisted  upon,  and  municipal  control  of  the  quarantine  should 
be  possible.  The  diet  should  be  in  small  amounts,  and  prin- 
cipally of  milk,  especially  if  vomiting  is  a  prominent  symptom. 
It  may  be  necessary  to  peptonize  the  milk,  or  to  give  one  of  the 
predigested  foods. 

Fresh  air  is  most  essential  and  the  more  these  children  are  out 
of  doors  the  better.  The  room  temperature  should  range  between 
55°  F.  and  60°  F.  The  tendency  to  bronchitis  must  be  remem- 
bered and  the  child  perfectly  protected  from  draughts. 

Local  and  Medicinal. — A  great  number  of  drugs  have  been 
recommended  for  pertussis,  but  no  one  can  be  relied  upon  in 
every  case.  A  much-vaunted  remedy  is  the  vaporizing  with  a 
lamp  of  one  of  the  phenol  preparations.  This  has  been  reported 
of  service  by  some,  but  is  a  dangerous  remedy  as  carbolic  acid 
poisoning  is  a  possibility.  The  room  full  of  fresh  air  is  decidedly 
more  beneficial. 

Internally  several  remedies  are  used  more  generally  than 
others,  viz.,  antipyrine,  bromide,  quinin,  codeine,  belladonna 
and  bromoforra. 

Antipyrine  can  be  used  in  doses  of  1  grain  to  each  year  of 
the  age,  up  to  3  grains  every  two  hours,  with  syrup  of  tolu  as 
a  vehicle.  Quinin  can  be  added  to  this  prescription  or  given 
alone,  up  to  3  grains  at  a  dose,  or  with  glycyrrhiza  or  yerba 


404 


THE   DISEASES   OP    CHILDREN. 


santa.     Bromide   can    always   be    given    with    either    of   these 
mentioned. 


"^wi  \  i 


c 

0 

ei 


Fig.    73. — The    whooping-cough   belt.      (Kilmer.) 


Fig.    74. — Rear    view    of    the    whooping-cough    belt    applied.      (Kilmer.) 

Codeine  is  a  valuable  assistant  to  any  of  the  above,  and  can 
be  given  for  its  effect. 

Belladonna  is  probably  best  given  in  the  form  of  the  fluid 


CONTAGIOUS   DISEASES.  405 

extract  (1/2  min.)  or  tincture  (2  min.)  doses,  and  it  must  be 
given  for  its  physiological  effect. 

Bromoform  is  a  dangerous  drug,  because  of  the  difficulty  of 
forming  a  perfect  mixture,  and  the  invariable  settling  of  por- 
tions of  it  to  the  bottom,  and  the  last  two  or  three  doses  con- 
taining perhaps  a  lethal  dose  of  the  drug.  I  have  seen  three 
children  put  to  sleep  for  many  hours  by  being  given  the  last 
three  doses  in  the  bottle. 

Sior  ^  recommends  the  use  of  euchinin  as  a  substitute  for 
quinin  in  the  treatment  of  whooping-cough.  It  is  recommended 
in  doses  of  a  centigram  for  each  month,  and  a  decigram  for 
each  year,  twice  a  day,  morning  and  night,  given  in  sugar,  milk 
or  cold  chocolate.  It  can  also  be  given  in  suppositories.  The 
report  of  the  cases  in  which  it  was  used  showed  a  cessation  of 
vomiting,  disappearance  of  cyanosis  and  a  shortening  of  the  dura- 
tion. 

Dr.  T.  W.  Kilmer  has  reported  a  number  of  cases  materially 
benefited  and  the  attack  shortened  by  the  wearing  of  an  abdom- 
inal binder,  made  of  linen  with  a  strip  of  elastic  webbing  under 
each  arm  and  lacing  up  the  back.  He  claims  for  it  that  the 
paroxysms  are  reduced  in  severity  and  number,  vomiting  relieved 
and  complications  less  frequent. 

One  of  the  several  preparations  of  chestnut  leaves  may  be  used 
with  good  effect  in  some  cases. 

After  the  child  has  ceased  coughing  it  should  be  given  a  tonic, 
which  will  make  up  the  leucocytosis  and  low  hemoglobin  which 
is  nearly  always  present. 

The  employment  of  pertussis  vaccine  as  a  prophylactic  and 
curative  agent  has  been  successfully  used. 

As  a  prophylactic  agent  two  injections  are  given,  25  million 
the  first  dose,  and  in  four  days  fifty  million.  As  a  curative 
agent  four  injections  are  given  at  intervals  of  four  days,  the 
initial  dose  being  but  25  million. 

PAROTITIS. 

Synonyms. — Mumps,  epidemic  parotiditis. 
Etiology. — The  infecting  organism  is  not  known.     It  is  very 
contagious,  occurs  epidemically  as  well  as  in  endemics;  affects 


iJahrb.   fur  Kinderhk.,    1908,    p.   452. 


406  THE   DISEASES   OP    CHILDREN. 

children  more  often  than  adults,  and  chiefly  between  one  and  five 
years  of  age.  The  contagion  is  taken  into  the  system  through 
the  nose  or  mouth  and  from  close  contact.  Immunity  is  con- 
ferred by  one  attack. 

Symptoms. — The  incubation  period  may  be  as  long  as  three 
weeks,  though  it  is  usually  much  shorter.  There  are,  as  a  rule, 
one  or  two  days  of  lassitude,  headache,  anorexia,  perhaps  nausea 
and  vomiting.  The  temperature  usually  reaches  101°  to  103° 
F.,  and  is  at  its  height  with  the  enlargement  of  the  parotid  glaud. 
The  parotids  usually  enlarge  by  the  fourth  day,  assuming  large 
proportions.  The  child  complains  of  pain  or  soreness  on  swal- 
lowing, stiffness  at  the  angle  of  the  jaw,  during  and  after  eating 
the  glands  usually  feel  very  tense.  .Acids  usually  cause  great 
pain  on  swallowing. 

The  swelling  primarily  may  not  be  very  great,  it  is  located  di- 
rectly under  the  lobe  of  the  ear  and  is  soft  and  elastic  on  palpa- 
tion. It  gradually  increases  in  size.  After  about  ten  days  the 
swelling  subsides,  the  stiffness  in  the  jaws  and  the  pain  on  swal- 
lowing disappear. 

Complications. — A  coincident  involvement  of  the  submaxillary 
glands  may  occur,  and  there  may  be  a  metastasis  in  the  testicles 
or  ovaries.  In  males  there  is  pain  in  the  scrotum,  wdth  rise  in 
temperature,  probably  preceded  by  a  chill.  The  epididymis  be- 
comes enlarged  and  tender,  and  there  may  be  an  involvement 
of  the  testicle  also.  With  an  ovaritis  in  the  female  there  may 
be  pain  and  enlargement  of  the  breasts.  Earache  with  or  with- 
out deafness  is  often  seen. 

Prognosis.— Barring  complications  the  prognosis  is  uniformly 
good. 

Treatment. — Isolation  and  protection  from  exposure  are  the 
chief  indications.  The  application  of  heat  to  the  enlarged  gland 
is  of  service  in  relieving  pain.  The  glands  should  be  covered 
by  a  piece  of  dry  flannel  by  carrying  the  bandage  under  the 
chin  and  over  the  ears,  and  pinning  on  the  top  of  the  head. 

A  laxative  should  always  be  given  early  in  the  attack,  prefer- 
ably calomel  followed  by  a  mild  saline. 

The  diet  should  be  liquid  as  chewing  is  usually  painful.  The 
mouth  should  be  cleansed,  and  if  an  orchitis  develops  the  testicle 


CONTAGIOUS   DISEASES.  407 

should  be  supported  by  hammock-like  arrangement  made  by 
folded  towel  or  a  suspensory.  Guaiacol  in  25  per  cent  ointment 
has  been  found  serviceable  in  many  cases  of  epididymitis,  giving 
great  relief  from  swelling  and  pain. 


LA  GRIPPE. 

Synonyms. — Influenza,  grip. 

Etiology. — This  is  due  to  the  invasion  of  the  bacillus  known 
as  Pfeiffer's  bacillus,  described  first  in  1892.  It  is  short  and 
small,  and  is  found  in  the  secretions  from  the  nose  and  respira- 
tory tract.  It  grows  on  various  media  to  which  blood  has  been 
added.  It  stains  with  a  carbolfuchsin,  10  per  cent  solution. 
They  appear  either  in  masses  or  threads  of  short,  thick  rods  and 
resembles  a  diplococcus  with  rounded  ends.  They  are  found  in 
the  pus  cells  which  are  present  in  the  nasal  secretions  later  in 
the  disease,  and  at  this  time  the  streptococci  and  staphylococci 
are  associated  with  the  Pfeiffer  bacillus.  It  gains  entrance 
through  the  respiratory  mucous  membrane. 

Epidemics  of  grip  have  been  described  for  years  and  they 
sweep  over  the  whole  country  at  intervals.  It  attacks  both  adults 
and  children,  but  without  regularity.  More  children  seem  af- 
fected in  some  epidemics  than  adults.  It  may  occur  at  any  age, 
and  is  readily  communicable  from  one  person  to  another.  Some 
persons  are  specially  susceptible,  having  recurrences  both  during 
the  same  and  different  epidemics. 

Pathology. — There  is  no  distinct  pathology  due  to  the  bacillus 
itself,  the  pathological  changes  being  chiefly  due  to  the  bacteria 
usually  found  with  it.  These  changes  are  chiefly  a  catarrhal 
condition  of  the  respiratory  mucous  membrane.  There  may  be 
a  general  enlargement  of  the  lymph  nodes  and  of  the  spleen.  In- 
volvement of  any  organ  or  membrane  may  be  present,  and  tuber- 
culosis may  easily  be  engrafted. 

Symptoms. — Several  types  are  encountered  in  an  epidemic,  the 
chief  symptoms  being  referred  to  the  respiratory  organs,  the  mus- 
cular system,  the  nervous  system  or  the  gastroenteric  tract.  The 
symptoms  of  each  type  may  be  present  with  those  of  one  being 
most  prominent. 


408  THE   DISEASES   OF    CHILDREN. 

In  all  forms  there  is  apt  to  be  the  initial  chill,  followed  by 
fever  up  to  103°  or  104°  F.  The  period  of  invasion  is  short 
and  generally  without  special  symptoms,  not  more  than  a  week 
and  the  incubation  a  day  or  so,  during  which  time  there  is  usu- 
ally a  dull  headache,  loss  of  appetite  and  irritability.  Usually 
the  prostration  is  out  of  all  proportion  to  the  symptoms. 

In  the  respiratory  form  there  are  signs  of  a  cold  in  the  head, 
sneezing,  suffusion  of  the  eyes  and  swelling  of  the  nasal  mucous 
membrane.  This  is  followed  by  a  cough  and  expectoration,  with 
probably  pain  in  the  chest.  The  physical  signs  are  those  either 
of  a  bronchitis  or  a  bronchopneumonia,  according  to  the  involve- 
ment. The  occurrence  of  pain  on  inspiration,  hurried  respira- 
tion and  pulse,  in  the  pneumonic  ratio,  and  a  rise  in  temperature 
is  usually  enough  to  complete  the  diagnosis.  Usually  there  is 
more  or  less  muscular  aching  in  this  variety  also.  The  bacilli  can 
be  found  in  the  nasal  secretions. 

In  the  muscular  form,  following  the  chill  and  initial  vomiting, 
there  is  headache  and  pain  in  the  back,  joints  and  muscles  of  the 
arms  and  legs.  The  child  cries  w^hen  handled  and  prefers  to  lie 
in  its  bed.     The  fever  is  quite  high,  and  the  pulse  accelerated. 

In  the  nervous  form  there  may  be  convulsions  in  the  very 
young,  with  severe  headache  when  the  child  is  able  and  old 
enough  to  complain;  there  is  photophobia,  great  restlessness,  ir- 
ritability and  nervousness.  The  prostration  is  severe  and  con- 
valescence more  prolonged  in  this  type.  Where  convulsions  are 
present  meningitis  may  be  suspected,  and  a  lumbar  puncture 
needed  to  clear  up  the  diagnosis. 

The  gastroenteric  form  is  seen  oftenest  in  the  younger  patients. 
Vomiting  is  always  present,  the  bowels  being  also  upset  Avith 
thin,  green  and  mucous  stools  at  frequent  intervals.  There  is 
anorexia  and  coated  tongue,  with  tympany,  restlessness  and 
fever. 

Complications. — The  chief  complications  are  the  inflamm.a- 
tions  of  the  respiratory  tract  found  in  all  of  the  varieties.  These 
may  be  caused  by  the  influenza  bacillus  alone,  but  usually  there 
are  associated  the  pyogenic  cocci  as  well. 

Transient  albumen  may  be  found  in  the  urine  or  a  true  ne- 
phritis may  follow  an  attack. 


CONTAGIOUS   DISEASES.  409 

One  of  the  most  frequent  complications  is  an  involvement  of 
the  sinuses  contiguous  to  the  nares  and  the  ear.  Frontal  sinus 
inflammation,  middle-ear  inflammations  and  mastoiditis  are  very 
frequent.  During  the  last  epidemic  in  this  section  of  the  coun- 
try these  complications  were  of  very  frequent  occurrence. 

Malnutrition  and  athrepsia  may  follow  acute  grip  in  younger 
children.     Synovitis  may  occasionally  be  seen  as  a  complication. 

Diagnosis. — In  the  presence  of  any  epidemic  the  diagnosis  is 
usually  easy,  but  in  most  cases  it  must  be  made  by  exclusion. 
Bacteriological  diagnosis  is  difficult  as  Pfeiffer's  bacillus  is  not 
easy  to  find  or  to  grow. 

A  complicating  tonsillitis  or  bronchitis  makes  the  diagnosis 
more  difficult.  The  following  diseases  must  often  be  excluded, 
bronchopneumonia,  especially  the  central  type,  pyelitis,  and  ton- 
sillitis. The  fact  that  the  prostration  in  influenza  is  apt  to  be 
more  profound  than  in  any  of  the  diseases  mentioned  is  an  aid  in 
differentiation. 

Prognosis. — Uncomplicated,  the  prognosis  is  good;  with  a 
pneumonia  it  is  more  or  less  grave.  Severe  gastrointestinal  com- 
plications are  difficult  to  recuperate  from.  Convulsions  make 
the  progress  less  favorable. 

Treatment. — Isolation  of  cases  of  grippe  is  most  important. 
Children  should  be  carefully  isolated  from  other  members  of 
the  family,  ill  with  influenza.  Keep  the  patient  strictly  in  bed, 
in  a  well  ventilated  room,  giving  easily  digested  and  nutritious 
food.  Milk,  diluted,  is  the  best  all-round  food,  except  in  the  gas- 
trointestinal type,  in  which  the  cereal  gruels  and  broths  are  best. 

An  initial  dose  of  calomel,  followed  by  oil,  is  of  great  benefit. 

The  coal-tar  products  should  be  given  with  the  greatest  cau- 
tion, and  never  without  one  of  the  diffusible  heart  tonics  is  given 
with  it,  as  caffeine  alkaloid,  1/10  grain,  camphor,  10  minims  of  a 
10  per  cent  oil  solution,  hypodermatically,  or  strychnia,  1/200 
grain,  to  a  child  of  two  years. 

The  salicylates  have  the  best  reputation  as  affording  relief  from 
the  pain  and  can  be  given  in  any  form,  perhaps  best  in  the  form 
of  aspirin,  in  1  to  3  grain  doses  to  a  child  of  two  years.  Codeine 
can  be  used  to  advantage. 

Quinin  to  older  children  can  be  combined  with  the  aspirin  in 


410  THE   DISEASES   OF    CHILDREN. 

capsule  or  yerba  santa  as  a  vehicle.     Vigorous  stimulation  may 
be  needed  and,  of  course,  when  needed  it  is  urgent. 

In  no  other  condition,  perhaps,  is  a  tonic  treatment  so  indicated 
as  in  the  convalescence  from  la  grippe,  and  especially  in  the 
respiratory  and  gastrointestinal  forms,  some  preparation  of  cod 
liver  oil  is  of  the  greatest  benefit. 

Hydrotherapy  for  the  fever  in  the  form  of  sponge  or  full 
baths. 

DIPHTHERIA. 

Definition. — This  is  an  acute  infectious  and  transmissible 
disease,  characterized  by  the  deposit  of  a  false  membrane,  caused 
by  the  action  of  a  specific  organism,  the  Klebs-Loeffler  bacillus. 
The  pseudomembrane  may  develop  on  any  raucous  surface  or  on 
a  denuded  area  on  the  skin.  It  is  primarily  a  local  disease,  and 
the  severe  general  symptoms  and  the  complications  are  due  to 
the  toxins  formed  by  the  bacilli. 

Etiology. — Diphtheria  is  caused  by  the  Klebs-Loeffler  bacillus. 
In  the  majority  of  cases  the  source  of  the  infection  cannot  be 
traced.  It  may  be  endemic  or  epidemic.  IVIilk,  contaminated 
f(X)d,  toys,  cats,  feeding  utensils,  books,  clothing,  linen,  etc.,  may 
carry  the  bacillus.  No  race  or  people  is  more  prone  to  develop 
diphtheria  than  another.  Infants  under  six  months  are  rarely 
affected  and  adults  are  much  less  susceptible.  It  is  most  frequent 
between  one  and  ten  years  of  age,  perhaps  the  most  cases  during 
this  period  occurring  between  three  and  five  years. 

The  most  potent  predisposing  cause  is  the  condition  of  the 
nose  and  throat,  accompanying  adenoids,  chronically  enlarged 
tonsils  and  chronic  nasal  catarrh.  Any  condition  of  the  gen- 
eral system  which  lowers  the  resistance  will  act  as  a  predis- 
posing cause,  as  la  grippe,  bronchitis  or  other  pulmonary 
diseases. 

Bacteriology. — No  attempt  will  be  made  to  give  an  exhaustive 
description  of  the  Klebs-Loeffler  bacillus,  the  reader  being  re- 
ferred to  special  works  on  bacteriology  for  that.  It  is  of  interest 
to  note  that  it  was  not  until  188.S  that  Klebs  first  described  a 
bacillus  constantly  found  in  throats  of  patients  dying  of  diph- 
theria, and  a  year  later  when  Loeffler  obtained  the  bacillus  in 
pure  culture  and  gave  his  knowledge  to  the  world. 


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CONTAGIOUS   DISEASES.  411 

The  bacillus  is  aerobic,  but  grown  also  without  oxygen,  and 
grows  best  on  serum  media.  It  is  rod  shaped,  straight  or 
slightly  curved.  Usually  with  clubbed  ends,  varying  greatly  in 
its  measurements.  It  stains  with  ordinary  aniline  dyes,  the  most 
satisfactory  perhaps  being  Loeffler's  methylene-blue  stain. 

In  bright  sunlight  the  bacillus  will  not  long  survive,  but  it 
does  live  for  a  long  time  in  the  dark,  in  the  mouth,  and  on  toys, 
etc.  Disinfectants  have  a  very  speedy  effect.  It  is  killed  at  (70° 
C,  136°  F.)  with  five  minutes'  exposure. 

When  other  bacilli  are  present  in  diphtheria  it  is  called  a 
mixed  infection.  The  most  frequently  associated  forms  of  bac- 
teria found  are  the  streptococcus,  staphylococcus  and  pneumococ- 
cus.  It  has  been  shown  that  the  primary  invasion  is  not  infre- 
quently with  the  streptococcus,  the  diphtheria  bacillus  being  en- 
grafted upon  the  soil  prepared  for  it. 

The  streptococcus  is  most  frequently  the  cause  of  some  of  the 
complications  met  with  in  diphtheria,  chief  of  which  is  broncho- 
pneumonia. 

The  Membrane. — Membrane  may  appear  upon  the  mucous 
membranes  of  the  nose  and  throat  due  to  other  organisms  than 
the  Klebs-Loeffler  bacillus.  The  characteristic  diphtheria  exu- 
date is  of  a  grayish-white  color,  and  is  firmly  attached  to  the 
underlying  mucous  membrane.  When  it  is  removed  it  leaves 
a  bleeding  area  beneath.  There  is  a  swelling  of  the  membrane 
surrounding  due  to  an  edema. 

The  development  of  an  exudate  on  the  tonsil  alone  may  be  a 
simple  follicular  tonsillitis,  and  when  no  history  of  exposure  is 
given  it  may  be  difficult  to  make  a  positive  diagnosis,  but  the 
appearance  of  a  membrane  upon  the  mucous  membrane  of  the 
nose,  nasopharynx  or  uvula,  is  very  suspicious  of  a  true  diph- 
theria. 

Cultures  from  this  membrane  will  clear  up  a  diagnosis,  and 
this  may  often  be  necessary. 

Bacteriological  Diagnosis. — Sterile  blood  serum  is  best  used 
for  the  first  growth.  A  culture  is  obtained  from  the  throat  by  a 
probe,  the  end  of  which  is  wound  with  sterile  absorbent  cotton. 
This  is  rubbed  over  the  membrane,  being  careful  not  to  touch 
any  other  part  of  the  throat  or  tongue.     The  child  is  held  with 


412  THE   DISEASES   OF    CHILDREN. 

face  in  good  light,  and  tongue  held  down  with  depressor.  The 
inoculated  swab  is  then  rubbed  over  the  surface  of  the  blood 
serum  of  the  culture  tube,  without  breaking  the  surface. 

The  tube  is  incubated  at  a  temperature  of  37°  C.  for  12  hours; 
experts  can  differentiate  at  the  end  of  five  hours.  With  a  plat- 
inum needle  a  number  of  the  colonies  are  scraped  off  the  culture 
medium,  some  of  this  is  washed  off  on  to  a  cover  glass  with  a 
drop  of  water.  The  cover  glass  is  air-dried,  passed  three  times 
through  a  tiame,  stained  with  an  alkaline  methylene-blue  solu- 
tion (Loeffler's)  for  10  minutes,  cold.  It  is  then  rinsed,  dried 
and  mounted  in  balsam.  It  is  examined  with  a  1/12  oil-immer- 
sion lens.  The  diphtheria  bacilli  may  be  found  in  great  num- 
bers, or  a  few  with  a  preponderance  of  streptococci  in  chains. 

Direct  examination  of  the  exudate  is  uncertain  and  unsat- 
isfactory. 

Virulent  bacilli  have  been  found  in  healthy  throats,  and  nu- 
merous observations  have  been  made  which  show  they  persist 
in  throats  for  a  long  period  of  time  after  the  disappearance  of 
the  exudate.  Park  ^  reports  one  case  in  which  they  were  found, 
eight  months  after  the  disappearance  of  the  membrane.  A  pseu- 
dobacillus  less  virulent  is  sometimes  found  in  the  throat,  but  it 
is  believed  these  have  been  derived  from  the  virulent  form. 

TJie  bacilli  generate  a  poison  or  toxin,  and  this  can  be  obtained 
from  cultures  of  living  bacilli,  by  filtration  through  porcelain. 

An  artificial  immunitj^  can  be  produced  in  the  economy  by 
the  introduction  of  an  antitoxin,  a  substance  which  will  act  as 
an  antidote  to  the  toxin.  Natural  immunity  more  or  less  active 
may  exist  in  the  human  being.  The  blood  serum  of  a  person 
convalescent  from  diphtheria  contains  this  antitoxin,  but  it  dis- 
appears after  a  few  weeks. 

Diphtheria  antitoxin  -  is  obtained  by  first  growing  a  virulent 
culture  of  bacilli,  sterilizing  them  by  adding  carbolic  acid  solu- 
tion. The  solution  is  siphoned  off,  leaving  the  bacilli  at  the 
bottom.  If  0.005  cc,  when  injected  into  a  guinea-pig,  will  kill 
it  promptly  it  is  of  the  correct  strength ;  250  grains  weight  of 
this  solution,  or  enough  to  kill  5000  guinea-pigs,  is  injected  into 
a  horse,  and  this  is  repeated  every  three  to  five  days,  or  until 


'Park:   Pathogenic  Bacteria  and  Protozoa.  ^Park:   loc.    cit. 


CONTAGIOUS  DISEASES.  413 

the  fever  reaction  has  subsided.  This  is  kept  up  until  at  the  end 
of  20  months  10  to  20  times  the  amount  originally  given  is  used. 
At  the  end  of  six  months  the  horse  is  bled  from  the  jugular 
vein,  and  from  the  serum  of  this  blood  the  antitoxin  is  obtained. 

The  antitoxin  is  standardized  by  inoculating  a  guinea-pig 
weighing  250  grams  with  100  or  with  10  fatal  doses  of  standard- 
ized toxin,  with  which  has  been  incorporated  an  amount  of  anti- 
toxin believed  to  be  sufficient  to  protect  from  the  toxin.  If  the 
guinea-pig  lives  for  four  days,  but  dies  soon  after,  the  amount 
of  antitoxin  added  to  the  toxin  was  just  one  unit. 

Pathology. — A  study  of  the  exudate  or  pseudomembrane  is 
the  chief  consideration  in  this  section,  though  the  pathological 
changes  occurring  as  complications  must  be  considered. 

The  pseudomembrane  may  be  situated  on  any  mucous  mem- 
brane of  the  body  or  upon  the  skin  upon  which  there  is  an  ab- 
rasion. In  the  order  of  frequency  of  involvement  might  be  men- 
tioned the  tonsils,  uvula,  nasopharynx,  nose,  conjunctiva,  larynx, 
trachea,  and  vagina. 

The  exudate  is  grayish-white  in  color,  and  dips  down  into  the 
mucous  membrane  beneath,  being  intimately  attached,  and  leaves 
a  bleeding  surface  when  pulled  off.  It  is  composed  mostly  of 
fibrin,  leucocytes  and  diphtheria  bacilli  in  pure  culture  or  mixed 
with  the  other  organisms  previously  mentioned. 

The  nerves  are  specially  acted  upon  by  the  toxins,  the  periph- 
eral nerves  being  the  ones  chiefly  affected.  This  degenera- 
tion may  be  parenchymatous,  interstitial  or  fatty.  The  cord 
and  brain  may  undergo  degeneration  also.  The  muscles  may 
show  a  degenerative  change  without  nerve  involvement.  One 
of  the  principal  muscles  involved  is  that  of  the  heart,  fatty  infil- 
tration and  degeneration  being  the  chief  change. 

Bronchopneumonia  is  frequent,  but  chiefly  due  to  the  asso- 
ciated bacilli,  streptococcus,  staphylococcus  and  pneumococcus. 

The  lymphatic  glands,  especially  about  the  neck,  are  enlarged 
due  to  cell  infiltration  with  occasional  hemorrhages. 

The  kidneys  may  show  involvement  also  from  the  toxins, 
similar  to  the  degeneration  accompanying  the  other  acute  infec- 
tious diseases.  The  parenchyma  and  glomeruli  are  principally 
involved. 


414 


THE   DISEASES  OF    CHILDREN. 


Symptoms. — The  clinical  classification,  according  to  the  loca- 
tion of  the  membrane,  we  consider  the  best.  If  a  bacteriologic 
examination  is  made  it  may  be  further  classified  according  to 
these  findings,  a  pure  culture  of  the  diphtheria  bacillus  or  a 
mixed  infection,  in  which  other  bacteria  are  found  in  addition 


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Fig.   75. — Laryngeal  and  nasal  diphtheria;   intubation. 

to  the  Klebs-Loeffler  bacillus.  These  are  chiefly  the  streptococcus, 
staphylococcus  and  pneumoeoccus. 

The  onset  is  usually  gradual;  the  child  may  complain  of  gen- 
eral malaise,  beginning  frequently  with  vomiting.  The  fever 
does  not  run  a  characteristic  curve,  its  height  and  course  de- 
pending upon  the  amount  of  toxemia,  the  amount  of  the  individ- 
ual resistance  or.  immunity,  and  the  amount  of  mixed  infection. 
In  mixed  infection  it  is  apt  to  run  much  higher  than  in  pure 
culture  form.  It  is  present  to  some  extent  in  all  eases  averaging 
from  101°  F.  to  102°  F. 

The  pulse  rate  is  always  increased,  depending  upon  the  amount 
of  toxemia,  and  not  in  proportion  to  the  height  of  the  tempera- 


CONTAGIOUS  DISEASES.  415 

tiire.  A  very  rapid  pulse  is  not  a  good  sign.  The  younger  the 
patient  the  more  rapid  the  pulse. 

The  child  may  or  may  not  complain  of  its  throat,  may  only 
have  pain  on  swallowing,  or  severe  dysphagia  may  be  present. 
The  degrees  of  this  symptom  depends  entirely  upon  the  amount 
of  infiltration  in  the  tissues  of  the  throat. 

The  tonsils  and  uvula  may  be  covered  with  a  thick  exudate 
and  the  child  not  complain  of  its  throat,  especially  if  it  has  been 
hurt  previously  in  an  examination  of  the  throat,  and  if  but  a 
little  sore,  fears  another  examination.  Hence,  the  importance 
and  the  absolute  necessity  of  examining  the  throat  in  every  sick 
child  as  a  matter  of  routine. 

The  membrane  described  above  is  found  on  one  or  both  tonsils 
or  the  uvula  in  addition.  The  glands  are  enlarged  about  the 
angle  of  the  jaw  and  at  the  back  of  the  neck. 

The  child  refuses  nourishment  or  takes  very  little  at  a  time. 
The  urine  is  high  colored  and  much  more  scanty  than  normal. 
According  to  the  amount  of  toxemia  will  albumin  and  casts  be 
found.  The  urine  should  be  regularly  examined  for  albumin, 
and  when  present  a  microscopic  examination  made  also,  though 
a  microscopic  examination  should  be  made  as  a  routine  measure. 

Generally  a  leucocytosis  is  present,  its  amount  depending  upon 
the  membranous  inyplvement.  The  hemoglobin  and  red  blood 
cells  are  relatively  decreased. 

If  there  is  nasal  involvement  there  will  be  a  discharge  from 
the  nostrils,  which  is  apt  to  be  blood  tinged,  and  an  excoriation 
of  the  skin  of  the  upper  lip  occurs.  There  is  obstruction  to 
the  breathing  through  the  nose  and  in  the  breast  or  bottle  fed, 
nursing  is  interfered  with.  The  nasal  variety  occurs  infre- 
quently in  the  very  young,  and  it  may  be  seen  as  a  primary 
lesion,  though  it  usually  occurs  as  a  complication  of  the  faucial 
form. 

iMy  experience  bas  been  that  in  primary  nasal  diphtheria  the 
symptoms  are  as  a  rule  more  severe  than  in  the  uncomplicated 
faucial  variety,  though  there  are  eases  in  which  the  diagnosis 
may  not  be  made.  Where  the  diagnosis  is  not  made,  and  the 
case  looked  upon  as  one  of  a  severe  "cold,"  it  is  a  great  menace 
as  a  distributor  of  the  infecting  organism.     If  both  fauces  and 


416  THE   DISEASES  OP    CHILDREN. 

nares  are  covered  with  membrane  the  toxemia  is  apt  to  be  very 
severe. 

If  the  membrane  occurs  in  the  larynx,  as  a  primary  condition, 
there  are  apt  to  be  three  stages,  the  stage  of  invasion,  in  which 
the  child  is  listless,  has  some  fever,  perhaps  a  slightly  croupy 
cough,  and  lasts  from  a  few  hours  to  24 ;  the  spasmodic  stage,  in 


Fig.   76.      A.  Diphtheritic  casts  nf  trachea   and  })ronchi.      B.   Diphtheritic  cast  of  nose. 
(Case  of   Dr.   Lee  Kahn.) 

which  the  membrane  has  formed.  In  this  the  croupy  symptoms 
are  exaggerated,  the  cough  more  spasmodic,  there  is  very  decided 
stridor,  with  recession  of  the  suprasternal  and  supraclavicular 
spaces.  As  a  late  phenomenon,  before  the  third  stage  or  stage 
of  asphyxia  occurs,  the  intercostal  spaces  and  epigastric  region 
recede  with  each  inspiration.  In  the  stage  of  asphyxia  all  the 
extraordinary  muscles  of  respiration  are  brought  into  play. 

From  the  beginning  of  the  second  stage,  when  obstruction 
has  begun  from  the  membrane  forming,  the  child  is  restless,  sleeps 
fitfully,  and  the  depression  is  very  profound.  The  pulse  is  ac- 
celerated out  of  ratio  to  the  respiration. 


CONTAGIOUS   DISEASES.  417 

As  obstruction  advances  there  is  cyanosis,  blueness  of  the  lips 
and  about  the  nose,  finger  and  toe  nails,  clammy  skin,  cold  ex- 
tremities, and  unless  relieved  death  quickly  ensues. 

The  enlargement  of  the  lymph  nodes  of  the  neck,  and  at  the 
angle  of  the  jaw  is  quite  marked  in  all  of  these  forms. 

Complications  and  Sequelae. — The  Kidneys. — Albuminuria  oc- 
curs in  about  60  per  cent  of  cases,  and  in  a  smaller  percentage 
there  are  evidences  of  a  parenchymatous  degeneration,  hyaline 
and  granular  casts,  with  occasionally  blood  casts. 

Lungs. — In  the  mixed-infection  cases  bronchopneumonia  is 
a  frequent  complication.  The  consolidation  is  usually  along  the 
posterior  borders  of  the  lungs,  patchy  in  its  extent.  This  com- 
plication is  less  often  seen  in  pure-culture  forms  of  diphtheria. 

The  first  evidence  of  a  complicating  pneumonia  is  a  sudden 
increase  in  the  number  of  respirations  with  dilatation  of  the  ate 
nasi  and  a  rise  in  the  temperature. 

Bronchitis  is  frequently  seen  evidenced  by  an  increase  in  the 
cough,  respirations  more  rapid  and  slight  rise  in  temperature. 

Nervous  System. — Perhaps  the  most  important  changes  occur 
in  the  nervous  system  as  a  result  of  the  toxemia.  These  compli- 
cations were  more  often  encountered  before  the  antitoxin  was  dis- 
covered. 

The  changes  are  those  of  a  fatty  degeneration,  usually,  and 
it  evidences  itself  by  paralyses  of  various  muscles.  It  most 
often  begins  during  the  stage  of  convalescence,  perhaps  several 
days  after  the  case  has  been  dismissed,  though  it  may  occur 
early.  The  group  of  muscles  most  frequently  involved  is  of  the 
throat,  chiefly  of  the  palate,  and  will  not  be  noted  until  there  is 
a  regurgitation  of  liqui*ds  through  the  nose  as  the  child  swal- 
lows; attempts  at  swallowing  may  be  followed  by  spasmodic 
coughing  from  the  liquid  falling  into  the  glottis.  In  this  form 
of  paralysis  the  muscles  usually  recover  their  tone  in  three  or 
four  weeks. 

Any  muscle  or  group  of  muscles  may  be  involved,  the  eye,  legs 
or  arms.  Cases  of  sudden  death  are  most  often  due  to  a  paralysis 
of  the  heart. 

Diagnosis. — Considerable  doubt  may  exist  in  one's  mind  as 
to  the  true  condition  existing  in  a  case  of  membranous  deposit 


418  THE  DISEASES  OF    CHILDREN. 

on  the  mucous  membrane  of  the  throat  or  nose,  which  can  only 
be  decided  by  a  bacteriologic  examination. 

However  in  a  case  presenting  a  dirty-white  membrane  in  the 
throat  or  nose  which  is  not  easily  removed,  a  slight  rise  of  tem- 
perature, enlargement  of  the  lymph  nodes,  with  evident  prostra- 
tion, as  the  element  of  time  plays  so  important  a  role  in  treat- 
ment, it  is  safe  to  administer  the  antitoxin  at  once  and  confirm 
the  diagnosis  by  bacteriologic  examination  later. 

Follicular  tonsillitis  is  more  often  mistaken  for  diphtheria. 
In  this  the  tonsils  are  enlarged,  but  the  edema  of  surrounding 
tissue  is  not  so  great,  and  if  seen  early  the  follicles  containing 
the  whitish  deposit  are  discrete.  It  is  later,  when  these  coalesce 
over  the  surface  of  the  tonsil,  that  the  diagnosis  is  doubtful,  but 
there  is  no  tendency  for  the  membrane  to  spread.  When  coal- 
esced it  can  be  more  easily  mopped  off.  The  constitutional 
symptoms  are  more  severe  and  the  onset  more  sudden.  The 
temperature  is  higher  also.  General  aching  is  present  as  a  rule 
even  in  young  children,  and  they  complain  when  handled.  How- 
ever, even  though  the  diagnosis  seems  clear,  especially  when  other 
children  are  in  the  house,  a  bacteriologic  diagnosis  should  be 
made. 

Quinsy. — A  peritonsillar  abscess  may  be  confounded  with 
diphtheria.  In  a  case  under  my  observation  recently  the  con- 
sultant laryngologist  believed  the  condition  a  diphtheria,  but  at 
my  request  endeavored  to  find  pus  by  an  incision,  without  suc- 
cess. Twenty-four  hours  later  spontaneous  rupture  of  the  ab- 
scess occurred  below  the  incision,  which  confirmed  my  diagnosis 
and  cleared  up  all  symptoms.  There  is  very  often  an  exudate 
over  the  affected  tonsil  and  mucous  membrane  adjacent  which 
can  be  removed  without  difficulty. 

If  but  one  side  is  affected  the  swelling  is  chiefly  of  tliat  side, 
and  the  edema  of  surrounding  tissue  quite  severe.  The  patient 
talks  as  if  the  mouth  was  full  of  mush. 

Croup. — This  form  of  trouble  may  be  either  catarrhal,  false 
croup,  or  diphtheritic,  true  croup,  and  without  visible  membrane 
in  the  throat  the  diagnosis  may  be  difficult.  Direct  inspection 
of  the  epiglottis  is  possible  in  the  very  young,  but  not  .in  the 


CONTAGIOUS  DISEASES.  419 

older  children,  and  inspection  by  means  of  the  laryngeal  mirror 
is  impossible  in  the  child. 

In  catarrhal  croup  the  child  is  awakened  by  a  harsh,  brassy, 
spasmodic,  croupy  cough,  having  been  put  to  bed  usually  with- 
out anything  having  been  noticed  unusual  in  its  condition.  It 
may  have  had  a  slight  evidence  of  ''cold"  in  the  head  for  a  day 
or  so  previously.  There  may  be  some  stridor,  with  evidence  of 
obstruction  to  inspiration,  but  without  recession,  and  but  a 
slight  rise  of  temperature.  By  morning,  as  a  rule,  it  is  com- 
fortable, and  but  little  cough  is  noticed,  but  when  it  does  cough 
it  is  of  the  same  brassy,  harsh  character.  These  symptoms  have 
a  tendency  to  recur  for  one  or  two  nights  subsequently.  A  few- 
doses  of  ipecac,  20  or  30  drops  of  the  syrup,  or  antimony  and 
ipecac  tablets  (1/100  grain  each),  repeated  at  one-  or  two-hour 
intervals,  a  cold,  wet  compress  to  the  throat  and  a  steam-laden 
atmosphere  for  it  to  breathe,  usually  give  relief  in  this  form. 
It  would  be  best  to  apply  the  term  * '  croup ' '  to  the  catarrhal  form 
only. 

After  tonsillectomj'  the  abraided  surface  is  covered  with  a 
necrotic  looking  membrane,  which  resembles  the  diphtheritic 
membrane  very  much. 

Prognosis. — This  depends  to  a  very  great  extent,  in  this  day 
of  antitoxin,  to  the  promptness  with  which  the  diagnosis  is  made 
and  the  first  injection  of  antitoxin  given. 

It  depends  greatly  also  upon  the  age  of  the  patient.  The 
younger  the  child  the  graver  the  prognosis.  The  site  of  the 
lesion  also  influences  the  prognosis.  In  purely  tonsillar  or  phar- 
yngeal cases  the  outlook  is  better,  the  nasal  form  less  so, 
and  the  laryngeal  cases  very  bad.  The  mortality  in  the  laryngeal 
cases  requiring  intubation,  even  with  the  antitoxin,  is  very  high. 

Treatment. — In  no  disease  has  the  mortality  been  so  influenced 
as  it  has  in  diphtheria  by  the  use  of  the  diphtheria  antitoxin. 
Statistics  show  the  mortality  has  been  reduced  50  per  cent  since 
the  antitoxin  era  began. 

Prophylaxis. — This  is  most  important  and  is  best  accomplished 
by  the  medical  inspection  of  schools;  removal  of  diseased  and 
enlarged  tonsils  and  adenoids,  strict  quarantine  of  affected  chil- 


420  THE  DISEASES  OF   CHILDREN. 

dren;  careful  disinfection  of  all  bedding,  clothes,  feeding  uten- 
sils and  rooms  vacated  by  those  who  have  been  affected ;  bacterio- 
logical examination  of  the  throat  before  the  child  is  dismissed, 
with  a  general  bath  after  leaving  the  room ;  extreme  care  on  the 
part  of  physician  and  nurse  when  entering  and  leaving  the 
sick  room,  and  the  immunization  of  the  children  in  the  family 
or  ward  exposed  to  it. 

Immunizing  doses  of  antitoxin  are  usually  advised  as  fol- 
lows :  for  infants  300  units,  500  units  for  children  up  to  15  years, 
and  1000  units  for  adults.  The  immunity  from  this  dosage  lasts 
from  two  to  four  weeks.  This  dosage  should  be  repeated  if  it  is 
desired  to  prolong  the  immunity.  Since  the  introduction  of  the 
concentrated  form  of  antitoxin  the  complications  formerly  seen 
are  less  frequent,  viz.,  the  rash  and  severe  urticaria. 

After  the  child  has  recovered,  the  woodwork  of  the  room 
should  be  first  wiped  down  with  a  solution  of  1 :60  carbolic  acid, 
and  then  disinfected  with  formaldehyd  or  formaldehyd  and  sul- 
phur, or  permanganate  of  potash. 

Curative  Treatment. — As  soon  as  the  diagnosis  has  been  posi- 
tively made,  a  curative  dose  of  diphtheria  antitoxin  should  be 
given.  To  a  child  of  five  years  an  initial  dose  of  not  less  than 
3000  units  should  be  given.  If  the  toxemia  is  severe,  fever  high, 
membranous  exudate  extensive,  the  dose  should  be  5000  units. 
Where  no  improvement  follows  within  8  to  12  hours  a  second 
injection  should  be  made.  In  laryngeal  cases  the  initial  dose 
should  not  be  less  than  10,000  units. 

A  large  number  of  reliable  antitoxins  are  upon  the  market 
now  and  one  should  be  chosen  which  is  furnished  in  a  sterilized 
syringe  with  sterilized  needle  and  attachments. 

The  concentrated  serums  are  preferable,  as  they  less  fre- 
"quently  cause  the  disagreeable  rashes  seen  when  larger  volumes 
of  blood  serum  were  used. 

The  effect  of  the  serum  is  usually  prompt  and  decided.  The 
temperature  falls  1°  F.  or  2°  F.  within  two  or  three  hours,  the 
child  soon  becomes  tranquil  and  falls  asleep.  The  most  typical 
effect  is  that  upon  the  membrane,  within  24  hours  it  begins  to 
curl  up  at  the  edges,  and  gradually  peels  off  and  becomes  de- 


CONTAGIOUS  DISEASES.  421 

taehed  either  in  its  entirety  or  in  places.  TJie  swelling  and 
congestion  of  the  mucous  membrane  become  less  marked. 

The  serum  is  best  injected  in  the  loose  tissue  of  the  back  be- 
tween the  shoulders  or  in  the  loin.  The  advantage  of  this  is  the 
child  does  not  see  the  preparations  for  the  operation  and  is  easily 
held  while  it  is  being  done.  Careful  preparation  should  be  made 
of  the  skin  by  soap  and  water  cleansing,  followed  by  alcohol,  the 
sterile  covering  of  the  needle  not  being  removed  until  everything 
is  ready.  The  point  of  injection  is  covered  by  an  inch-square 
piece  of  zinc  oxide  adhesive  plaster,  or  sealed  with  collodion. 

Complications  Following  Antitoxin. — More  than  19  cases  have 
been  reported  of  sudden  death  following  the  use  of  diphtheria 
antitoxin.  The  cause  of  these  fatalities  has  not  been  satisfac- 
torily proven,  but  it  is  supposedly  in  cases  of  so-called  status 
lymphaticus,  and  death  occurs  within  a  few  minutes  after  the 
injection.  Some  exhibit  alarming  symptoms,  sudden  dyspnea, 
fainting,  cyanosis  and  feeble,  rapid  pulse  with  recovery.  These 
are  believed  to  be  phenomena  due  to  the  horse  serum  and  not  to 
the  antitoxin  it  contains,  von  Pirquet's  theory  being  that  they 
are  due  to  the  antibodies. 

Skin  eruptions  before  the  concentrated  serum  was  used 
occurred  quite  frequently.  These  rashes  were  scarlatinaform 
or  urticaria],  when  of  the  latter  variety  accompanied  with  great 
itching.  Occasionally  enlargement  of  the  joints  occurred. 
There  is  quite  regularly  a  rise  in  temperature  when  these  compli- 
cations occur. 

General  and  Medicinal  Treatment. — Concentrated  and 
nourishing  food  should  be  given,  milk,  in  small  quantities,  and 
as  often  as  every  two  hours ;  animal  broths  and  beef  juice.  Gav- 
age  and  rectal  nourishment  should  be  used  if  necessary.  Ene- 
mata  for  constipation ;  hydrotherapy  for  temperature  over  102° 
F. ;  sponge  or  tub  baths.  Stimulation  is  quite  regularly  indi- 
cated, and  only  a  good  bottled-in-bond  whisky  or  brandy  should 
bo  given.  The  (piantity  for  24  hours,  half  an  ounce  to  an  ounce, 
should  1)0  diluted  with  2  or  8  ])arts  of  water,  and  this  given  at 
rr(M|ut'nt  intervals  as  indicated  during  the  day  and  night.  This 
can  be  supplemented  by  the  hypodermic  injection  of  strychnia 


422  THE  DISEASES  OF   CHILDREN. 

grain  1/200  to  grain  1/100  according  to  the  patient's  age,  or 
strophanthus  by  the  mouth.  The  bowels  should  be  specially 
watched. 

Bromide  and  chloral,  or  Dover's  powder,  can  be  given  in  cases 
of  extreme  restlessness.  Sedatives  are  usually  indicated  in  the 
tube  eases  on  account  of  the  extreme  restlessnsss  from  asphyxia 
and  spasmodic  coughing.  Tonics  following  the  attack  are  spe- 
cially indicated. 

Absolute  rest  in  bed  in  a  well  ventilated  room  is  the  first  req- 
uisite. It  must  be  possible  to  effectually  quarantine  the  sick 
room. 

Local  application  of  cold  to  the  throat  is  beneficial  in  form  of 
wet  cold  compresses  or  an  ice  bag. 

Local  Treatment. — Rarely  is  it  necessary  to  use  any  local  treat- 
ment in  these  eases  after  the  injection  of  the  antitoxin.  The 
exhaustion  following  the  struggle  always  accompanying  swab- 
bing of  the  throat  is  more  harmful  than  if  the  throat  is  let  alone. 
In  the  nasal  forrti  it  may  be  necessary  to  irrigate  the  nose  to  open 
the  nares.  This  is.  done  by  enveloping  the  child  in  a  towel  or 
sheet,  holding  it  on  its  side  on  the  nurse's  lap,  protected  by  a 
rubber  sheet,  and  with  fountain  sj^ringe  containing  a  warm 
boracic  acid  solution  or  normal  saline  solution,  one  drachm  to 
the  pint,  held  2  feet  above  its  head,  the  upper  nostril  is  irrigated, 
the  solution  returning  through  the  lower  one.  With  head  slightly 
lower  than  the  body  there  is  no  danger  of  the  fluid  being  aspi- 
rated in  the  lungs. 

INTUBATION. 

To  the  late  Dr.  Joseph  0  'Dwyer  of  New  York  is  due  the  per- 
fection of  the  intubation  tube  for  the  relief  of  stenosis  of  the 
larynx.  In  1883,  after  many  months  of  trial  and  experimenta- 
tion, Dr.  0 'Dwyer  brought  to  the  notice  of  the  profession  gen- 
erally the  intubation  tube  which  he  had  perfected.  It  is  due  to 
Dr.  0 'Dwyer 's  memory  to  state  that  practically  the  only  im- 
provements that  have  ever  been  made  in  the  tube  were  made  by 
Dr.  0 'Dwyer  himself  before  his  death,  the  most  perfect  ones 
in  use  to-day  being  those  made  according  to  the  O  'Dwyer  pattern. 
The  tubes  are  made  according  to  scale,  usually  in  five  sizes,  corre- 


CONTAGIOUS   DISEASES. 


423 


spending  to  the  age  of  the  child.  They  are  made  of  metal,  gold 
plated,  and  have  a  central  swell  which  holds  them  in  position, 
and  a  head  and  narrow  neck  which  fits  in  the  chink  of  the  glot- 
tis. 

In  selecting  the  tube  for  the  age  of  the  child  the  scale  is  con- 
sulted, and  the  smallest  tube  which  will  remain  in  position  is 
chosen.  The  tube  reaches  to  within  a  short  distance  of  the  bifur- 
cation of  the  trachea.  The  rest  of  the  set  consists  of  a  mouth 
gag,  with  which  the  child's  mouth  is  held  open;  and  introducer. 


Fig.    77. — O'Dwyer   Intubation  Tubes. 

upon  the  end  of  which  is  screwed  the  obturator,  and  an  extractor 
or  the  extubator.  In  some  of  the  late  models  of  intubation  sets 
each  of  the  tubes  contain  an  obturator  easily  attached  to  the 
shank  of  the  introducer.  Upon  the  side  of  the  head  of  the 
tube  there  is  a  small  opening  into  which  is  inserted  a  piece  of 
thread  long  enough  to  reach  beyond  the  mouth  of  the  child  in 
order  to  make  it  easy  to  remove  the  tube  in  ease  the  opening  be- 
comes blocked  with  dislodged  membrane,  or  if  it  has  been  pushed 
into  the  esophagus  instead  of  the  larynx. 

Indications  for  Intubation. — An  intubation  tube  is  never  intro- 
duced unless  positive  indications  for  its  use  are  present.  If  in 
spite  of  the  use  of  the  diphtheria  antitoxin  the  child  has  increas- 
ing asphyxia,  evidenced  by  cyanosis  and  marked  retraction  of 
the  spaces  above  the  sternum  and  the  clavicles,  of  the  intercostal 
spaces  and  the  epigastric  region,  it  is  imperative,  in  order  to 
save  the  child's  life,  that  a  tube  be  inserted.     Under  these  condi- 


424  THE  DISEASES   OF    CHILDREN. 

tions  the  patient  is  extremely  restless,  its  respiration  is  very 
rapid  and  there  is  gradual  deepening  of  the  color  to  a  deep  cy- 
anotic hue. 

Operation. — 0  'Dwyer  originally  advocated  the  introduction  of 
the  tube  with  the  child  in  an  upright  position,  but  it  may  be 
conveniently  introduced  with  the  child  upon  its  back,  with  its 
chin  slightly  raised.  The  child  should  be  wrapped  carefull)^ 
from  shoulders  beyond  its  feet  in  a  sheet,  thus  confining  its  arms 
and  legs.  The  child  is  held  upon  the  right  side  of  the  lap  of  the 
nurse,  its  head  resting  against  her  chest,  one  of  her  arms  en- 
circling the  lower  part  of  the  chest,  the  other  steadying  the  head 
with  hand  upon  the  forehead.  If  enough  resistance  is  at  hand 
the  nurse  holding  the  child  uses  both  arms  to  hold  its  body  in 
position  and  the  assistant  steadies  the  head  and  holds  the  gag 
which  has  been  introduced  into  the  mouth.  Many  operators 
prefer  to  introduce  the  tube  with  the  child  lying  upon  its  back, 
wrapped  in  a  sheet  as  described. 

After  selecting  the  proper  tube  the  thread  is  placed  in  posi- 
tion through  the  hole  in  the  head  of  the  tube  and  the  intubator 
is  examined  to  find  if  it  can  slip  off  the  tube  from  the  obturator 
easily.  The  thread  is  held  firmly  in  the  hand  which  is  to  be 
used  to  introduce  the  tube,  the  index  finger  of  the  unengaged 
hand  is  carried  into  the  mouth  and  the  epiglottis  located  and 
pulled  forward,  and  the  tube  is  then  carried  with  the  index  finger 
as  a  guide  directly  into  the  larynx.  With  the  attachment  on  the 
intubator  the  tube  is  slipped  off  its  obturator  and  the  obturator 
quickly  withdrawn,  the  tube  being  pushed  home  by  the  finger 
still  within  the  mouth. 

As  soon  as  the  tube  has  been  pushed  home  there  is  an  instant 
change  in  the  character  of  the  cough.  It  now  becomes  harsh 
and  brassy,  and  a  good  deal  of  spasmodic  cough  is  caused.  The 
child  coughs  more  than  it  did  before,  and  occasionally  may 
cough  up  through  the  tube  small  pieces 'of  membrane.  After 
the  first  paroxysm  of  coughing  the  child  usually  falls  into  a  sound 
sleep,  the  cough  gradually  lessens  and  the  whole  picture  is 
changed. 

Some  advocate  the  leaving  of  the  thread  in  the  mouth,  curling 
it  up  and  placing  it  at  the  posterior  margin  of  the  tongue  between 


CONTAGIOUS  DISEASES. 


425 


the  cheek  and  the  gum,  but  this  usually  proves  very  unsatis- 
factory. As  soon  as  it  is  certain  that  the  tube  will  not  be 
coughed  up  the  finger  is  carried  into  the  mouth  after  reintro- 


Fig.    78. — Position    for    intubation.      First    step. 


Fig.    79. — Intubation.      Second   step.      Introducer   about   to   be   removed. 

ducing  the  gag  and  with  the  finger  on  the  tube  the  thread  is  cut 
and  slowly  withdrawn. 

The  length  of  lime  it  will  be  necessary  for  the  tube  to  be 
worn  varies  very  greatly.  Some  cases  have  been  reported  in 
which  the  tube  could  not  be  dispensed  with  before  the  end  of 


426 


THE  DISEASES  OF   CHILDREN. 


three  weeks.  It  is  well,  as  a  rule,  to  allow  the  tube  to  remain  in 
position  for  not  less  than  five  days,  and  if  at  the  end  of  this  time 
the  fever  has  subsided  and  the  respirations  are  normal  it  may 
be  safe  to  remove  the  tube,  having  everything  at  hand  necessary 
for  its  reintroduction  in  case  a  spasmodic  condition  arises  again, 
necessitating  its  reintroduction. 

Extubation. — After  close  watching  of  the  patient  it  is  decided 
that  the  tube  can  be  removed,  the  child  is  prepared  as  for  intu- 
bation.    The  gag  is  inserted,  the  index  finger  carried  to  the  tube 


Fig.    80. — Position   for   feeding   child   wearing   intubation   tube. 

and  the  extractor  with  beak  closed  is  carried  down  to  the  tube 
along  the  finger  as  a  guide,  placed  in  the  opening,  thumb  is  de- 
pressed, beak  opened  and  by  lowering  the  hand  the  tube  is  with- 
drawn. 

Feeding. — During  the  wearing  of  the  tube  it  is  very  necessary 
that  the  child  be  fed  in  the  recumbent  position,  with  its  head  well 
over  the  edge  of  the  bed,  or  the  nurse's  lap,  and  below  the  level 
of  its  body.  Usually  the  child  is  very  easily  fed  in  this  position, 
and  will  either  take  its  milk  or  food  from  a  spoon  or  a  bottle. 
This  position  was  first  suggested  by  Dr.  Cassellberry  of  Chicago, 
and  has  been  of  very  great  service.  Only  liquids  should  be  given 
until  the  tube  is  removed. 

This  operation  has  practically  entirely  superseded  the  old 
operation  of  tracheotomy,  which  is  the  making  of  an  opening 
in  the  trachea  immediately  below  the  cricoid  cartilage. 


CONTAGIOUS   DISEASES.  g  427 

INCUBATION  AND  QUARANTINE  IN  CONTAGIOUS 
DISEASES. 

The  following  is  the  report  of  the  Committee  on  Quarantine 
of  the  Medical  Society  of  the  County  of  Dutchess  (New  York), 
embracing  suggestions  regarding  periods  of  incubation  and 
quarantine  in  contagious  diseases,  and  are  reproduced  because 
of  their  conciseness : 

Small-pox. 

Small-pox  is  considered  the  most  infectious  of  all  diseases. 
Period  of  incubation  1  to  10  days  in  the  great  majority  of 
cases;  shortest  time  5i/4  days,  longest  time  16  days. 

Prophylaxis. — Vaccination,  revaccination  and  isolation.  Vac- 
cination may  render  one  immune  to  the  disease  up  to  the  fourth 
day  after  exposure. 

Quarantine  should  continue  until  all  the  affected  epidermis  is 
removed — the  dried  discs  and  scales  containing  infectious  mate- 
rial. Each  case  is  one  unto  itself,  and  no  definite  time  other  than 
stated  can  be  given. 

Diphtheria. 

Period  of  incubation,  24  hours  to  7  days. 

Prophylaxis. — Isolation,  disinfection,  antidiphtheritic  inocu- 
lation.    Plenty  of  fresh  air. 

Quarantine  should  continue  until  at  least  two  cultures  from 
the  throat  prove  negative  to  the  diphtheritic  bacillus  by  bacterio- 
logical examination. 

Measles. 

The  second  most  infectious  disease  with  which  we  have  to 
deal.     Period  of  incubation,  9  to  11  days. 

Prophylaxis. — Isolation  during  whole  course  of  the  disease. 

The  disease  may  be  transmitted  from  the  first  symptoms  until 
after  the  desquamation,  but  as  the  eruption  begins  to  fade  the 
danger  of  transmission  diminishes,  and  during  the  period  of 
desquamation  the  probability  of  transmission  is  but  slight.  This 
point,  however,  is  a  mooted  one.  The  rule  is  isolation  until 
the  skin  is  perfectly  clear  and  normal,  and  there  are  no  nasal 
or  aural  discharges. 


428  *      THE   DISEASES   OP    CHILDREN. 

Scarlet  Fever. 

Scarlet  fevei*  is  considered  the  third  most  infectious  disease. 

Incubation. — As  short  as  24  hours ;  as  long  as  21  days ;  aver- 
age, 7  to  12  days. 

Prophylaxis. — Isolation  for  a  long  time,  at  least  until  des- 
quamation has  entirely  disappeared  and  the  skin  is  in  its  normal 
healthy  state,  and  there  are  no  nasal  or  aural  discharges.  Proper 
disinfection  and  hygienic  conditions  must  exist  during  whole 
course  of  the  disease.  Desquamation  in  this  disease  is  infectious 
as  well  as  the  discharges.  Serum  therapy  has  not  been  of  any 
avail  in  this  disease. 

German  Measles. 

Period  of  incubation  from  one  to  four  weeks,  average  time 
14  to  21  days. 

May  be  transmitted  by  contact  and  by  fomites.  Contagion 
seems  to  differ  in  different  epidemics.  The  best  authorities  state 
that  the  contagiousness  disappears  with  the  eruptions,  there- 
fore isolation  should  be  enforced  until  the  eruption  has  entirely 
disappeared. 

Whooping-Cough. 

Transmitted  by  direct  contact. 

Infection  begins  with  the  earliest  symptoms. 

Period  of  incubation  from  one  to  two  weeks. 

Prophylaxis. — Isolation  until  at  least  the  "whoop"  has  dis- 
appeared. 

Cerebrospinal  Meningitis. 

Transmitted  or  communicated  through  secretions  of  the  mouth, 
nose  and  conjunctivas,  but  it  has  not  been  determined  whether 
the  disease  is  communicated  to  human  beings  by  insects. 

Period  of  incubation  from  a  few  days  to  three  weeks. 

Prophylaxis. — Isolation,  disinfection.  Isolation  should  con- 
tinue until  the  mucous  membranes  are  free  from  meningo- 
coccus or  the  diplococcus  (meningitiditis)  intracellularis. 
Serum  therapy  has  been  used  successfully  in  some  cases. 

Chicken-Pox. 
Period  of  incubation  four  days  to  a  week. 
Prophylaxis. — The  person  infected  should  be  isolated  during 
the  entire  eruption  period  and  until  the  removal  of  the  scabs. 


CONTAGIOUS  DISEASES.  429 

It  must  be  considered  as  among  the  most  contagious  diseases, 
but  the  mode  of  infection  is  not  given. 

Mumps. 

Period  of  incubation  4  days  to  24,  average  two  weeks. 

Prophylaxis. — The  disease  is  transmitted  even  before  the 
symptoms  appear,  and  even  as  long  as  six  weeks  after  the  symp- 
toms have  disappeared. 

DISINFECTION. 

In  all  eases  of  infectious  or  contagious  diseases,  all  utensils, 
bedding,  toweling  and  clothing  of  every  kind  should  be  thor- 
oughly disinfected  and  fumigated.  Utensils,  by  the  use  of 
formalin,  carbolic  acid,  creolin  or  bichloride  solutions,  care 
being  taken  that  bichloride  solutions  do  not  come  in  contact 
with  metal.  All  dejecta  by  the  use  of  formalin,  copperas  or 
persulphate  of  iron  solutions.  Bichlorides  are  not  recommended 
for  use  in  dejecta  as  an  albuminate  is  formed  on  the  outside, 
and  proper  sterilization  is  therefore  prevented.  All  bedding 
should  be  saturated  in  a  formalin  solution  or  one  of  bichloride 
solution  before  being  sent  to  the  laundry.  Where  there  are 
proper  facilities,  all  bedding,  of  whatever  nature,  should  be 
thoroughly  sterilized  by  superheated  steam  or  by  dry  heat,  espe- 
cially this  should  be  done  with  all  mattresses.  In  institutions 
where  this  cannot  be  done  the  mattresses  and  all  bedding  should 
be  destroyed.  The  same  should  hold  for  private  practice,  but 
inasmuch  as  this  procedure  in  private  practice  would  work  a 
hardship  to  a  great  many  poor  people  the  physician  will  be  able, 
by  thorough  formalin  disinfection  and  fumigation,  to  prevent 
the  spread  of  the  disease.  The  bedding,  however,  should  be 
thoroughly  saturated  in  a  solution  of  formalin  sufficiently  strong 
to  be  eifective.     The  wind  will  clear  out  the  fumes. 

More  care  in  the  isolation  and  quarantine  for  measles,  scarlet 
fever  and  whooping-cough  should  be  exercised,  because  there  is 
no  known  medical  treatment  to  cut  short  the  course  of,  or  to 
render  people  immune  to  these  diseases.  With  diphtheria  and 
small-pox  the  old  pest-house  idea  should  be  abolished,  inasmuch 
as  every  one  coming  in  contact  with  these  two  diseases  may  be 
rendered  immune  by  the  proper  use  of  vaccine  virus  and  serum 
therapy;  the  same  is  probably  true  of  cerebrospinal  meningitis. 


CHAPTER  XVII. 
DISEASES  OF  THE  CIKCULATORY  SYSTEM. 

THE  HEART. 

Examination,  Defects,  Diseases. 

The  heart  is  placed  more  horizontally  in  the  chest  of  the 
child,  and  the  apex  beat  is  higher.  During  the  first  five  or 
six  years  it  is  found  in  the  fourth  interspace,  and  slightly  to  the 
outer  side  of  the  mammillary  line,  and  it  gradually  becomes 
lower  as  the  heart  enlarges,  until  it  is  found  in  the  fifth  inter- 
space. The  outline  can  be  made  out  by  percussion  with  ease, 
because  of  the  thinness  of  the  chest  wall,  and  for  this  reason 
light  percussion  is  necessary.  The  relative  dulness  extends 
from  the  right  border  of  the  sternum  to  beyond  the  left  mam- 
millary line. 

The  pulse  rate  in  the  infant  and  child  varies  with  the  age 
and  at  different  times  of  the  day  and  under  varying  conditions. 
The  following  rates  may  be  considered  average  for  various  ages : 

Newborn    120  to  160 

First  12  months 100  to  120 

Second  year 90  to  100 

Third  to  fifth  year 90 

The  blood  pressure  is  not  at  all  constant  nor  can  it  be  con- 
sidered a  very  valuable  aid  in  pediatrics.  The  following  rates 
of  blood  pressure  have  been  given  for  various  ages : 

Infancy    75  to     90  mm 

Children    90  to  100  mm 

Young   adults    100  to  135  mm 

An  examination  of  the  heart  should  include  careful  inspection, 
palpation,  percussion  and  auscultation.  From  inspection  we 
learn,  in  most  cases,  the  location  of  the  apex  beat,  the  presence 

430 


DISEASES   OP   THE   CIRCULATORY   SYSTEM.  431 

or  absence  of  dyspnea,  and  the  character  and  frequence  of  the 
breathing;  color  of  the  skin  and  nails;  position  of  the  patient; 
shape  of  the  finger  tips;  the  size  of  the  liver  and  spleen,  and  the 
amount  of  gaseous  distention  of  the  abdomen.  From  percussion 
the  relative  area  of  dulness  of  the  heart,  size  of  liver,  condition 
of  the  lungs,  back  and  front.  The  finger  is  the  best  pleximeter 
and  the  hand  and  fingers  the  best  percussion  hammer.  By 
palpation  the  apex  beat  can  be  located  and  its  force  determined, 
also  the  character  of  the  pulse.  It  can  be  learned  whether 
the  pulse  in  the  two  wrists  beats  with  the  same  volume,  the 
frequency  of  the  pulse  and  the  character  of  the  pulse  wave. 
From  auscultation,  the  character  of  the  sounds  of  the  heart,  the 
presence  or  absence  of  murmurs  or  a  bruit  or  friction  sounds; 
character  of  the  breathing  and  of  adventitious  sounds. 

Defects  of  the  heart  are  frequently  found  at  birth,  the  co7i- 
genital  heart  lesions,  which  may  eitlier  be  the  result  of  imperfect 
development  or  the  persistence  of  fetal  structures,  as  a  patent 
foramen  ovale,  or  a  stenosis  of  the  pulmonary  or  mitral  orifices. 
Stenosis  of  the  pulmonary  orifice  is  usually  due  to  fetal 
endocarditis. 

The  heart  lesions,  as  the  result  of  disease,  are  usually 
endocardial,  and  caused  by  the  infectious  diseases,  with  their 
organisms  and  toxins. 

Because  of  the  peculiar  susceptibility  of  the  heart  muscle  and 
its  lining  membrane  to  bacterial  invasion,  and  the  influence  of 
their  toxins,  the  changes  incident  to  these  complications  in  the 
infectious  diseases  as  in  typhoid  fever,  scarlet  fever  and  diph- 
theria are  greatly  to  be  feared. 

The  chief  disease  at  fault  is  rheumatism,  and,  as  mentioned 
in  the  section  on  that  subject,  a  rheumatic  heart  may  be  present 
with  but  few  or  no  joint  lesions,  tlie  heart  being  practically  the 
only  manifestation  of  the  disease. 

Scarlatina  and  diphtheria  cause  serious  heart  lesions,  mostly, 
due  to  the  effect  of  the  complicating  organism,  the  usual  one 
being  the  streptococcus.  Influenza  as  a  cause  of  acquired  heart 
disease  is  not  generally  believed,  but  I  have  seen  it.  Among 
the  predisposing  causes  may  be  mentioned  the  seasons,  violent 
physical  exercise,  anemia  and  chorea. 


432  THE   DISEASES   OP    CHILDREN, 

CONGENITAL  HEART  DISEASE. 

The  most  frequent  form  of  congenital  heart  disease  is  the 
permanent  patency  of  the  foramen  ovale.  Congenital  valvular 
lesions  are  also  found,  the  chief  being  of  the  pulmonary  orifices, 
as  the  right  side  of  the  fetal  heart  is  more  frequently  involved 
than  the  left.  The  opening  into  the  aorta  is  rarely  affected, 
though  it  may  be.  A  number  of  other  congenital  lesions  have 
been  found  post  mortem,  among  them  being,  impervious  or  con- 
tracted auriculo-ventricular  orifices ;  impervious  or  absent  aorta ; 
continuance  of  ductus  arteriosus  after  birth;  transposition  of 
aorta  and  vena  cava. 

Symptoms. — The  chief  symptoms  of  the  congenital  form  of 
heart  disease  is  the  early  cyanosis  and  the  heart  murmur. 

The  cyanosis  is  quite  marked,  especially  when  the  child  cries, 
the  skin  and  nails  and  mucous  membranes  are  blue,  and  the 
name  applied  to  these  blue  babies  is  morbus  ceruleus. 

Bronchitis  and  hroncliopneumonia  are  not  at  all  infrequent 
in  these  cases  from  passive  congestion,  and  principally  involve 
the  posterior  border  of  the  lungs.  Clubbed  fingers  and  toes  are 
often  seen.  These  children  are  backward  mentally  and 
physically. 

Dyspnea  and  orthopnea  are  frequent,  and  the  pulse  is  much 
increased  in  frequency.  With  rupture  of  compensation  edema 
of  the  lower  extremities  takes  place. 

Diagnosis. — The  diagnosis  of  pulmonary  stenosis  is  made 
principally  from  the  physical  signs.  The  presence  of  a  heart 
murmur  and  enlargement  of  the  heart  can  be  easily  made. 

The  murmur  is  systolic  in  character  and  as  a  rule  harsh  and 
loud,  and  heard  distinctly  over  considerable  area.  The  exception 
may  be  true,  a  soft-blowing  murmur  may  be  heard.  It  is  heard 
usually  best  at  the  base  and  transmitted  upward.  No  murmur 
may  be  heard. 

Auscultation  may  prove  very  unsatisfactory  in  regard  to  a 
correct  diagnosis  of  the  seat  of  the  lesion.  I  recall  one  case  in 
which  a  number  of  examinations  were  made  by  experienced 
diagnosticians,  and  numerous  opinions  given,  and  none  was 
correct,  as  shown  by  the  autopsy  findings. 


DISEASES   OF   THE   CIRCULATORY   SYSTEM,  433 

A  systolic  murmur  in  the  center  of  the  precordial  area  not 
transmitted  is  suggestive  of  a  patent  foramen. 

Prognosis. — This  is  always  grave,  since  children  veith  con- 
genital heart  lesions,  the  blue  babies,  rarely  survive  the  second 
year.  They  may  be  well  developed  at  birth,  but  soon  become 
anemic,  athreptic  and  emaciated.  As  a  rule  they  do  not  reach 
puberty.  Stoelker  gives  193  cases,  24  died  in  first  six  months; 
42  before  the  end  of  the  first  year;  56  before  the  tenth  year, 
and  71  before  the  twentieth  year. 

The  degree  of  cyanosis  and  dyspnea  influence  the  prognosis. 
If  these  children  can  be  placed  in  proper  surroundings  in  regard 
to  home  life,  climate,  etc.,  the  prognosis  is  better.  They  are 
susceptible  to  pneumonia,  especially  due  to  the  passive  pulmonary 
congestion. 

Treatment. — The  treatment  is  unsatisfactory  as  far  as  cure  of 
the  condition  is  concerned.  It  is  largely  symptomatic,  with  a 
general  supervision  over  the  diet,  exercise,  habits  and  clothing 
of  the  child.  It  should  have  tonics  and  nourishing  food,  which 
will  not  cause  an  attack  of  indigestion,  and  should  be  guarded 
against  the  contagion  of  the  exanthemata  and  pulmonary  dis- 
eases. Its  clothing  should  be  warm  and  changed  according  to 
the  seasons,  and  in  winter,  if  possible,  it  should  be  taken  to  a 
warmer,  more  equable  climate,  where  an  out-of-door  life  in 
the  sun  can  be  led.  The  exercise  must  never  be  violent,  but 
under  supervision.  If  digitalis  is  given  as  a  heart  tonic  it  should 
be  in  small  doses,  and  increased  in  the  presence  of  ruptured 
compensation.  Strychnia  or  strophanthus  are  valuable  adju- 
vants in  an  emergency.  Oxygen  for  extreme  cyanosis  is  of 
benefit. 

PERICARDITIS. 

Definition. — This  is  an  inflammation  of  the  serous  membrane 
enclosing  the  heart,  the  pericardial  sac. 

Forms. — It  occurs  as  an  acute  condition,  and  two  forms  are 
recognized,  the  dry  pericarditis  and  pericarditis  with  effusion. 

Etiology. — Dry,  Fibrinous,  Plastic. — It  is  most  frequently  a 
secondary  condition  to  a  general  infectious  disease.  The  bac- 
teria  localized  by  Flexner  are   chiefly   the   micrococcus   lance- 


434  THE   DISEASES   OF    CHILDREN. 

olatus,  streptococcus,  staphylococcus  aureus,  bacillus  pyocyaneus, 
influenza  bacillus  and  the  tubercle  bacillus.  Rheumatism  has 
long  been  looked  upon  as  a  cause,  and  it  may  occur  both  during 
the  attack  and  a  number  of  days  after  the  subsidence  of  the 
acute  rheumatic  symptoms.  Babcock  mentions  nephritis  as  a 
cause  of  pericarditis  not  often  thought  of.  Trauma  is  also  a 
cause. 

Pathology. — The  smooth  serous  membrane  is  injected,  there 
is  an  endothelial  desquamation  and  the  surface  is  roughened 
from  a  fibrinous  exudate.  Serofibrin  or  serum  may  be  thrown 
off,  enough  to  separate  the  two  layers,  but  they  may  adhere  and 
form  fine  fibrous  bands  or  a  more  dense  and  firm  set  of  adhesions. 
A  myocarditis  may  also  be  present. 

Symptoms. — This  condition  may  pass  unrecognized  unless  an 
examination  of  the  heart  is  made.  Suspicion  may  be  aroused 
by  the  rise  of  temperature,  which  follows  beginning  inflamma- 
tion of  the  pericardium. 

Pain  is  rather  a  constant  and  prominent  symptom  when  the 
child  is  old  enough  to  localize  it.  It  may  be  referred  to  the 
precordial  region,  the  epigastrium  or  even  between  the  shoulders. 
As  a  rule  it  is  not  very  sharp,  but  it  may  be  very  acute. 

The  temperature  is  quite  regularly,  elevated,  to  102°  F.  or 
perhaps  more.  The  presence  of  a  rise  in  temperature,  in  any 
of  the  exanthemata  or  rheumatism,  should  cause  the  heart  to  be 
investigated. 

The  pulse  and  respirations  are  both  accelerated.  There  may 
be  some  cough,  and  loss  of  appetite  is  usual; 

Physical  Signs. — The  prominent  physical  signs  are  those 
caused  by  the  roughened  pericardium,  viz.,  friction  fremitus 
and  friction  sounds.  Deep  pressure  by  the  palpating  fingers 
may  decrease  the  fremitus  felt  on  light  palpation.  The  friction 
sound  is  usually  best  heard  over  the  middle  of  the  precordium, 
on  both  systole  and  diastole.  The  area  of  heart  dulness  is 
increased,  quite  decidedly  so  if  there  is  any  effusion.  The  heart 
sounds  are  apt  to  be  somewhat  muffled. 

Occurrence. — Poynton  ^  gave  some  statistics  of  heart  disease 
in  children  as  follows :     "Of  150  fatal  cases  of  rheumatism  heart 


*  Babcock:   Diseases   of   the   Heart. 


DISEASES   OP   THE   CIRCULATORY    SYSTEM.  435 

disease,  there  was  evidence  of  more  or  less  acute  plastic  peri- 
carditis in  all  but  nine.  In  113  the  pericardium  was  more  or 
less  adherent,  while  in  77  the  adhesion  was  complete." 

Diagnosis. — From  endocarditis  by  the  absence  of  murmurs 
and  the  presence  of  friction  sounds,  pericarditis  with  effusion, 
the  apex  beat  is  displaced  or  absent.  In  pleurisy  with  effusion 
the  apex  beat  may  be  displaced,  but  the  area  of  flatness  is  much 
greater. 

Prognosis. — This  is  always  grave.  Occurring  as  a  complica- 
tion of  rheumatism  or  of  any  of  the  exanthemata,  it  is  es- 
pecially so. 

Treatment. — This  is  largely  symptomatic,  as  there  is  no 
method  of  aborting  the  trouble.  The  heart  condition  is  ben- 
efited by  the  use  of  remedies  to  combat  the  underlying  disease, 
active  antirheumatic  remedies  should  be  used  freely  when  that 
disease  is  present. 

Application  of  an  ice  bag  is  of  great  assistance.  A  small 
and  light  one  is  used,  and  not  completely  filled.  A  piece  of 
flannel  is  placed  between  the  skin  and  the  ice  bag,  gradually 
increasing  the  length  of  time  until  it  is  worn  continuously.  At 
first  it  is  kept  on  for  a  few  minutes  then  removed  for  a  short 
interval.  Hot  applications  can  be  used  but  not  with  the  same 
benefit. 

For  the  pain,  discomfort,  dyspnea  and  nervousness  opium  is 
of  benefit.  Heroin  may  also  be  used.  Hydrotherapy  may  be 
needed  for  the  temperature,  if  it  goes  much  above  102°  F.  The 
ice  bag  has  a  tendency  to  keep  the  fever  down. 
•  Digitalis  should  not  be  given  unless  positively  indicated, 
rather  give  strychnia  as  needed. 

PERICARDITIS  WITH  EFFUSION. 

The  exudate  in  this  form  may  be  serofibrinous,  purulent  or 
hemorrhagic.  Its  character  cannot  be  determined  unless  an 
exploratory  puncture  is  made. 

The  pathology  of  these  conditions  is  largely  the  same  as  the 
dry  pleurisy,  until  the  effusion  takes  place. 

Symptoms. — The  early  symptoms  before  the  effusion  are  those 
of  the  plastic  or  dry  pleurisy,  pain,  slight  cough,  restlessness, 


436  THE   DISEASES   OF    CHILDREN. 

rise  of  temperature  and  pulse,  etc.  As  the  effusion  takes  place 
the  pain  is  relieved,  and  the  symptoms  then  presenting  are 
chiefly  those  of  pressure. 

The  sac  is  distended  and  the  area  of  heart  dulness  is  changed 
in  shape,  the  rounded  apex  of  the  triangle  being  upward.  The 
heart  is  displaced  if  the  quantity  of  effusion  is  large,  the  apex 
beat  being  found  to  the  outside  of  the  left  nipple,  as  a  rule. 

The  pulse  is  usually  regular  but  compressible.  It  may  be 
intermittent. 

Rotch  ^  has  suggested  that  a  small  triangular  area  of  dulness 
is  found  at  the  lower  right  corner,  which  is  easily  made  out. 

Prognosis. — Depends  upon  the  characters  of  the  fluid  which 
is  contained  in  the  sac.  The  hemorrhagic  form  is  usually  quite 
rapidly  fatal.  Owing  to  the  serious  myocardial  changes  which 
may  take  place  the  prognosis  in  children  is  specially  bad. 

Treatment. — Practically  nothing  can  be  done  to  mitigate  the 
condition  other  than  has  been  recommended  in  the  previous 
section.  Rest,  ice  bag,  blood  letting,  etc.  The  special  indica- 
tions are  absolute  rest  in  bed,  opium  for  pain  and  restlessness. 
Salines  by  the  mouth  occasionally  and  aspiration  when  it  is 
indicated. 

Aspiration  is  done  without  much  discomfort.  The  needle 
is  introduced  preferably  in  the  fifth  interspace,  between  the 
nipple  line  and  the  sternum  border,  and  between  the  apex  beat, 
if  it  can  be  located,  and  the  lower  border  of  the  effusion,  as 
shown  by  the  flatness,  all  the  fluid  which  can  be  removed  being 
allowed  to  escape.  If  many  pressure  symptoms  are  present 
surgical  interference  is  imperative  promptly. 

Digitalis  is  used  when  indicated  only.  The  fat-free  tincture 
in  5  or  10  drop  doses  is  the  best  preparation,  and  used  for 
its  effect.  If  diuresis  is  specially  desired  the  infusion  of  digi- 
talis may  be  given  with  decided  benefit,  a  teaspoonful  to  a 
dessertspoonful  every  three  hours. 

Sleep  may  be  insured  by  chloretone,  in  2  or  4  grain  doses. 
Codeine,  gr.  14  to  i/^,  especially  indicated  if  there  is  any  cough 
present;  atropia  if  there  is  much  dyspnea. 


^  Rotch :  Pediatrics. 


DISEASES   OF   THE    CIRCULATORY   SYSTEM.  437 

CHRONIC  PERICARDITIS. 

The  process  in  this  variety  of  pericarditis  may  be  limited  to 
the  pericardium,  or  extend  through  to  the  tissues  of  the  medias- 
tinum. In  the  latter  form  there  are  usually  adhesions,  more 
or  less  dense  between  the  pericardium  and  the  mediastinal 
tissues. 

Pathology. — As  a  result  of  the  inflammatory  process  there  is 
a  new  connective  tissue  growth,  if  intrapericardial,  principally 
between  the  base  of  the  heart  and  pericardium.  Associated  with 
the  external  pericarditis  an  inflammation  of  the  adjacent  pleura 
may  take  place,  with  adhesions  between  pericardium  and  pleura. 
Earely  an  effusion  may  be  present  in  this  form. 

Etiology. — Tuberculosis  is  usually  the  cause  of  the  chronic 
form,  and  it  may  follow  the  recurrence  of  the  acute  forha.  It 
is  not  very  common  in  children. 

Symptoms. — There  may  be  no  special  symptoms,  save  perhaps 
dyspnea  on  exertion,  and  when  secondary  heart  changes  take 
place,  edema,  ascites,  cough.  Physical  examination  may  not 
reveal  any  distinctive  signs  whatever  in  connection  with  the 
heart,  but  may  reveal  the  presence  of  an  hepatic  engorgement. 
Nothing  may  be  found  during  life  whereby  a  positive  diagnosis 
can  be  made,  but  at  the  postmortem  the  adhesions  are  found. 

Treatment. — This  is  entirely  symptomatic.  The  engorgement 
of  the  liver  must  be  treated  by  appropriate  remedies. 

PYOPERICARDIUM. 

This  is  a  very  rare  and  fatal  condition. 

Etiology. — It  is  oftenest  due  to  a  general  pyemia,  as  may 
occur  from  otitis  media,  osteomyelitis,  etc.  In  young  children 
it  may  occur  as  a  complication  of  pulmonary  disease,  notably 
empyema,  and  due  directly  to  the  pneumococcus.  Sex  plays 
no  part  in  its  causation.  In  100  cases  reported  by  Poynton  ^ 
83  per  cent  occurred  before  the  fourth  year,  and  two-thirds 
between  the  ages  of  one  and  three  years.  The  exanthemata  are 
predisposing  causes. 

Pathology. — The  fluid  found  in  the  pericardium  varies  from 
fibrinopurulent  fluid  to  a  creamy  pus.  The  pericardium  is 
thickened  and  adhesions  frequent. 


British    Medical   Journal,    August    15,    1908. 


438  THE   DISEASES   OP    CHILDREN. 

Symptoms. — The  beginning  of  the  pericardial  infection  can- 
not be  accurately  told,  as  the  friction  sounds  usually  present  in 
pericarditis  are  not  nearly  as  often  present  as  in  the  other  vari- 
eties of  pericarditis. 

This  form  may  be  acute,  lasting  several  weeks,  or  chronic, 
running  a  much  longer  course. 

The  child  is  ill  from  the  beginning,  dyspnea  is  prominent. 
The  temperature  is  elevated  and  irregular,  the  pulse  feeble  and 
rapid. 

The  usual  signs  are  present  if  the  effusion  is  large  in  amount. 
Muffling  of  the  heart  sounds;  increased  dulness  over  the  pre- 
cordial region,  especially  upward  toward  the  left  clavicle. 

Prognosis. — These  cases  are  almost  universally  fatal,  and 
many  come  to  autopsy  without  the  diagnosis  having  been  made. 

Treatment. — Supportive  treatment  and  paracentesis  of  the 
pericardium  offers  the  only  hope  of  cure.  The  left  lower  margin 
of  the  cardiac  dulness  has  been  recommended  as  the  point  of 
selection. 

ENDOCARDITIS. 

Definition. — An  inflammation  of  the  lining  m'embrane  of  the 
heart,  the  endocardium,  affecting  chiefly  that  portion  forming 
the  valves.  In  fetal  life  it  is  the  right  side  which  is  oftenest 
affected. 

Etiology. — The  active  cause  of  endocarditis  is  bacterial,  and 
it  occurs  rarely  as  a  primary  affection,  more  often  as  a  com- 
plication, or  as  Babcock  terms  it,  a  manifestation  of  rheumatism, 
diphtheria  and  any  of  the  acute  exantheraatous  and  infectious 
diseases.  By  far  the  most  frequent  causes  are  rlieumatism  and 
chorea,  the  following  also  being  causes:  tonsillitis,  influenza, 
cerebrospinal  meningitis,  typhoid  fever  and  septic  infection. 

Pathology. — The  endocardium  becomes  cloudy,  swollen  and 
injected,  with  a  chief  pathologic  process  taking  place  in  the 
valves,  which  are  folds  of  endocardium.  At  the  point  of  great- 
est strain  there  may  be  a  break  in  the  surface  of  the  valve,  and 
a  deposit  of  fibrin  at  once  takes  place,  becomes  organized  and 
forms  what  are  called  vegetations.  These  may  be  broken  off, 
taken  up  by  the  circulation  and  form  emboli,  causing  infection 


DISEASES   OF   THE   CIRCULATORY   SYSTEM.  439 

in  remote  organs.  Staphylococci,  streptococci  and  influenza 
bacilli  may  be  found. 

Symptoms. — Many  cases  of  endocarditis  present  so  few  symp- 
toms that  they  go  unrecognized,  and  the  fact  that  the  inflamma- 
tion has  occurred  is  only  determined  by  a  chance  physical  exam- 
ination of  the  heart.  Kealizing  the  frequency  of  *the  occurrence 
of  this  manifestation,  careful  and  regular  and  frequent  exam- 
inations of  the  heart  should  be  made  during  the  course  of  every 
illness  in  a  child  especially  when  due  to  infectious  diseases  and 
rheumatism. 

There  may  be  a  sharp  rise  in  the  temperature  which  has  been 
on  the  decline,  previously,  and  with  it  pain  in  the  region  of  the 
heart  and  dyspnea  or  air  hunger,^  and  palpation. 

Physical  Signs. — The  pulse  shows  a  tumultuous  action,  ill  sus- 
tained and  frequent,  and  a  throbbing  of  the  vessels  of  the  neck. 
The  heart  sounds  are  roughened  or  muffled  and  there  is  prac- 
tically always  a  distinct  blowing  murmur  heard  over  the  pre- 
cordia  with  the  point  of  intensity  varying  according  to  the  valve 
involved.  The  murmur  may.  entirely  take  the  place  of  one  of 
the  sounds. 

Prognosis. — The  course  of  a  simple  or  rheumatic  endocarditis 
is  toward  recovery,  but  with  the  heart  left  in  a  crippled  condi- 
tion, a  leaky  or  an  obstructing  valve.  Cases  have  been  reported 
with  complete  recovery,  without  a  permanent  crippling  of  the 
valves.  Compensation  may  always  exist,  and  the  patient  suc- 
cumb to  any  other  condition.  Poynton  points  out  the  frequency 
of  an  inflammation  of  the  heart  muscle  in  fatal  endocarditis. 
If  a  vegetation  is  washed  off  in  the  blood  current  and  an  embolus 
result,  the  prognosis  is  influenced  according  to  the  location  of 
its  lodgement.  If  in  the  brain,  the  outcome  is  serious,  if  not 
as  to  life,  certainly  as  far  as  permanent  recovery  is  concerned. 

Treatment. — "With  the  first  evidence  of  chorea  or  rheumatism, 
the  child  must  be  put  to  bed  at  once  and  absolute  rest  in  bed 
maintained  throughout  the  attack.  At  the  first  evidence  of 
pain  in  the  precordial  region  an  ice  bag  should  be  applied,  with 
a  light  piece  of  flannel  between  it  and  the  skin.  Heat  in  excep- 
tional cases  may  be  more  acceptable. 

^  Babcock. 


440  THE   DISEASES   OF    CHILDREN. 

The  treatment  is  largely  symptomatic,  pain  is  controlled  by 
opium  in  some  of  its  forms;  bromides  for  the  restlessness,  and 
salines  and  calomel  when  indicated. 

The  remedies  which  should  be  avoided  are  digitalis,  aconite, 
veratrum  viride  and  all  of  the  coal-tar  products.  Digitalis 
increases  systole  and  throws  more  strain  on  the  valves ;  veratrum 
and  aconite  depress  the  circulation  too  much,  as  do  the  coal- 
tar  products. 

Strychnia  is  a  valuable  agent  later,  after  the  acute  symptoms 
have  subsided. 

As  a  routine  the  administration  of  the  salicylates  is  advisable. 
Aspirin  is  well  borne. 

The  diet  should  be  the  most  easily  digested,  those  foods  which 
have  a  tendency  to  form  gas  which  would  cause  pressure  symp- 
toms should  not  be  given  at  all. 

MALIGNANT  ENDOCARDITIS. 

Synonym. — Acute  ulcerative  endocarditis. 

Definition. — This  condition  is  an  inflammation  of  the  endo- 
cardium and  occurs  as  a  manifestation  or  complication  of  gen- 
eral septic  troubles,  and  is  rather  infrequent  in  children. 

Etiology. — This  is  essentially  a  septic  condition  due  to  the 
action  of  the  pus-producing  organisms  in  the  endocardium,  of 
which  the  most  commonly  found  are  streptococci,  staphylococci, 
pneumococci  and  diphtheria  bacillus.  The  process  is  more  apt 
to  be  engrafted  upon  an  endocardium  previously  inflamed. 

Pathology. — In  children,  in  whom  ulcerative  endocarditis  is 
comparatively  rare,  the  process  is  the  same  as  in  adults.  There 
is  an  exaggeration  of  the  condition  found  in  simple  endocarditis. 
As  its  name  implies,  there  may  be  an  ulcerative  condition  affect- 
ing chiefly  the  valves,  and  emboli  are  more  apt  to  occur.  These 
emboli  are  vegetations  full  of  the  infecting  organisms,  and  a 
similar  process  begins  wherever  they  lodge. 

Symptoms. — The  symptoms  are  those  of  a  general  s«'])tic  con- 
dition, and  unless  a  special  examination  is  made  of  the  heart, 
attention  at  first  is  not  called  to  this  part  at  all.  The  patient 
is  in  a  typhoid  state.     The  fever  is  usually  decidedly  intermit- 


DISEASES   OF   THE   CIRCULATORY   SYSTEM.  441 

tent  in  character  and  inclined  to  be  irregular,  perhaps  preceded 
by  a  chill,  frequently  reaching  high,  105°  F.,  or  over.  The  skin 
is  hot  and  dry,  except  during  the  free  sweats,  which  are  apt 
to  be  a  feature;  the  tongue  dry,  the  bowels  loose,  loss  of  appe- 
tite, the  pulse  weak  and  often  much  accelerated.  The  patient 
looks  profoundly  impressed  by  something  and  the  anemia  is 
progressive. 

The  physical  signs  may  be  very  indefinite,  perhaps  a  blowing 
murmur,  perhaps  none.  If  the  patient  develops  symptoms  of 
a  septic  nature,  following  on  a  simple  endocarditis,  the  diag- 
nosis is  usually  plain. 

Prognosis. — ^The  prognosis  is  grave,  nearly  all  cases  dying 
promptly. 

Treatment. — Beyond  removing  the  cause  of  the  general  sep- 
tic condition,  if  possible,  a  nutritious  diet,  judicious  stimulation 
and  rest,  there  is  little  that  can  be  done.  The  antistreptococcic 
serum  might  hold  out  some  hope  of  relief. 

CHRONIC  ENDOCARDITIS. 

The  form  of  endocarditis  usually  referred  in  children  to 
which  the  term  chronic  is  applied,  is  that  which  follows  the 
acute  endocarditis. 

Pathology. — The  process  following  an  acute  endocarditis  is 
that  of  repair,  an  absorption  of  the  vegetations  on  the  valves 
and  the  formation  of  connective  tissue.  This  may  result  in  a 
deformity  of  the  valves  preventing  their  perfect  closure,  allow- 
ing a  backward  flow^  of  the  blood,  a  regurgitation  or  insufficiency, 
or  an  interference  to  the  free  flow  of  the  blood  through  the 
valve,  a  stenosis  or  an  ohstruction. 

If  the  heart  muscle  develops  in  proportion  to  the  dilatation 
of  the  heart  cavities,  resulting  from  the  overwork  because  of 
the  obstruction  at  the  valvular  orifice  or  a  damming  back  of 
th((  current,  a  compensation  exists.  As  long  as  compensatory 
hypertrophy  exists  practically  no  symptoms  are  present,  and 
unless  the  chest  is  examined  it  may  go  unrecognized. 

The  symptoms  of  ruptured  compensation  are  practically  the 
same  in  all  the  valvular  lesions. 


442  THE   DISEASES   OF    CHILDREN. 

MITRAL  REGURGITATION. 

■  In  this  condition  the  mitral  valves  are  incompetent  to  hold 
the  blood  of  the  left  ventricle  from  regurgitation  into  the 
auricle  during  ventricular  systole. 

Pathology. — The  cusps  may  be  so  stretched  as  to  overlap  and 
allow  leakage ;  one  valve  may  be  contracted  following  the  deposit 
of  fibrous  tissue.  The  left  auricle  receives  blood  from  the  lungs 
and  from  the  ventricle  at  systole,  consequently  it  quickly  becomes 
dilated,  and  because  of  this  crowding  it  is  hypertrophied  in  its 
attempts  to  empty  itself.  When  this  compensation  exists  no 
trouble  results,  but  when  the  auricle  is  overpowered  the  blood 
dams  back  upon  the  lungs  and  serious  symptoms  supervene, 
passive  congestion  in  many  important  organs  resulting.  This 
condition  is  a  very  common  one  among  children. 

Symptoms. — Practically  no  symptoms  exist  during  the  main- 
tenance of  compensation.  There  may  be  a  visible  difficulty  in 
breathing  on  violent  exertion,  such  as  running  or  rushing  up 
steps,  Avith  a  coincident  increase  in  the  pulse  rate.  Children, 
however,  rarely  complain  of  this,  and  unless  they  evidence  some 
pallor  after  taking  this  undue  exercise,  it  may  not  be  recognized. 
These  children  may  develop  colds  more  readily,  and  owing  to 
the  strain  upon  the  right  side  of  the  heart  on  coughing  this 
symptom  should  be  closely  watched. 

With  rupture  of  compensation  and  the  general  passive  con- 
gestion there  is  bronchitis;  catarrhal  gastritis;  enlargement  of 
the  liver;  engorgement  of  the  hemorrhoidal  vessels;  nephritis; 
cyanosis  and  dyspnea.  Dropsy  is  one  of  the  last  symptoms  to 
develop. 

Physical  Signs. — Inspection. — With  the  chest  bared  the 
apex  beat  is  found  displaced  downward  and  to  the  left,  owing 
to  the  left  ventricular  hypertrophy.  If  the  right  ventricle  is 
enlarged,  epigastric  pulsation  may  be  noted. 

Percussion  shows  an  increased  area  of  heart  dulness. 

Auscultation. — There  is  a  systolic  murmur,  or  bruit,  loud 
and  blowing,  and  heard  most  distinctly  over  the  apex  beat. 
It  is  transmitted  under  the  arm  and  posteriorly  to  the  angle  of 
the  scapula.     It  is  synchronous  with  the  first  sound  of  the  heart, 


DISEASES  OP   THE  CIRCULATORY   SYSTEM.  .  443 

and  it  may  take  the  place  of  the  first  sound   entirely.     The 
second  sound  is  accentuated. 

Prognosis. — This  depends  entirely  upon  the  existence  of 
compensation.     It  is  always  grave  when  compensation  ruptures. 

MITRAL  STENOSIS  OR  OBSTRUCTION. 

This  is  an  interference  to  the  flow  of  blood  from  the  auricle 
into  the  ventricle,  and  is  usually  due  to  an  endocarditis. 

Pathology.— The  obstruction  may  be  caused  by  a  deposit  on 
the  valve  or  at  the  valvular  orifice,  narrowing  the  orifice  in 
either  event.  In  consequence  the  auricle  is  dilated  and  hyper- 
trophied,  and  the  left  ventricle  is  relatively  smaller  in  size.  A 
right  ventricular  hypertrophy  takes  place  from  increased  work 
thrown  upon  it  by  passive  congestion  of  the  lung.  This  lesion 
is  less  frequent  in  children  than  in  adults. 

Symptoms. — There  are  very  few  symptoms  in  the  absence  of 
ruptured  compensation.  Dyspnea  is  present  on  the  slightest 
exertion,  digestive  disturbances  are  common,  and  these  children 
are  below  par  physically.  There  may  be  pain  in  the  region  of 
the  heart,  cough  may  be  present,  edema  develops  early,  conges- 
tion of  the  kidneys  follows,  and  then  ascites.  Cyanosis  of  the 
skin  and  nails  develops  also. 

Physical  Signs. — Inspection. — A  distinct  impulse  may  be 
seen  at  the  base,  with  feeble  apex  beat,  which  may  be  but  slightly 
displaced  outward.     Clubbing  of  the  fingers  is  quite  noticeable. 

Palpation. — An  important  sign  is  thus  elicited,  the 
presytolic  thrill  being  felt.  This  is  a  distinct  thrill,  felt  in  the 
fourth  and  fifth  interspaces,  just  before  the  ventricles  contract, 
inside  the  mammary  line;  a  pulsation  can  also  be  felt  in  the 
epigastrium.  The  pulse  is  of  less  volume  than  normal  and 
slowed,  and  the  left  radial  may  be  found  the  weaker.  Percussion 
shows  an  increased  area  of  dulness  downward  and  to  the  right. 

Auscultation. — There  is  a  presystolic  bruit,  heard  with 
greatest  intensity  above  and  to  the  right  of  the  apex  beat,  and 
not  transmitted.  The  murmur  is  iruich  rougher  and  harsher 
than  the  regurgitant  murmur.  The  sounds  of  the  heart  arq 
normal,  except  perhaps  an  accentuation  or  the  reverse  of  an  in-, 
distinctness  of  the  pulmonary  second  sound.     Babcock  describes  a 


444  THE   DISEASES  OP    CHILDREN. 

* '  doubling  of  the  second  sound,  limited  to  the  mitral  area,  or  the 
apex. ' ' 

Prognosis. — This  is  one  of  the  graver  of  the  valvular  lesions. 
The  child  is  stunted  in  its  growth,  and  from  five  to  ten  years 
may  be  the  limit  of  its  existence.  Pulmonary  complications  are 
usually  the  cause  of  death. 

AORTIC  REGURGITATION. 

Synonyms. — Aortic  insufficiency,  incompetency. 

In  this  condition  the  left  ventricle  can  never  completely 
empty  itself  as  the  aortic  valves  are  incompetent  to  prevent  the 
blood  flowing  back  immediately  into  the  ventricle  during 
diastole. 

Pathology. — In  children  the  condition  is  due  to  an  endo- 
carditis, is  inflammatory,  and  as  a  result  the  cusps  are  con- 
tracted or  held  down  by  bands,  making  perfect  closure  impos- 
sible. Vegetations  may  be  so  placed  on  the  edge  of  the  valves 
as  to  prevent  closure. 

In  this  condition  an  enlarged  left  ventricle  is  the  first  change 
noted,  and  as  it  enlarges  it  may  cause  an  incompetency  to  develop 
in  the  mitral  orifice.  Compensatory  hypertrophy  occurs  early, 
and  the  wall  of  the  ventricle  may  be  very  thick,  1  or  II/2  inches 
thick.     This  heart  is  called  the  beef  heart  or  cor  hovinum. 

Symptoms. — As  in  the  other  conditions,  as  long  as  compensa- 
tion exists,  there  may  be  no  special  symptoms.  Palpitation  is 
not  infrequent  and  may  be  the  only  symptom.  It  is  to  the  pulse 
one  must  look  for  rupture  of  compensation.  It  becomes  weaker, 
and  the  typical  Corrigan  pulse  is  felt  if  the  child's  hand  is 
elevated  above  its  head.     The  pulsations  are  not  even  or  regular. 

Physical  Signs. — Inspection.— Visible  pulsation  may  be  noted 
in  the  larger  arteries  of  the  body,  notably  the  carotids,  but  this 
is  not  as  frequently  seen  in  children  as  in  adults.  The  apex 
beat  is  displaced  downward  perhaps  as  much  as  two  spaces,  and 
outward. 

Palpation. — The  cardiac  impulse  is  quite  strong,  the  heart's 
action  being  tumultuous.  The  characteristic  Corrigan  or  water 
hammer  pulse  is  present.  In  this  phenomenon  the  child's  hand 
being  held  higher  than  its  head,  the  finger  on  the  radial  artery 


DISEASES   OF   THE   CIRCULATORY   SYSTEM.  445 

feels  the  strong  pulsation,  and  the  artery  immediately  collapses. 
Percussion. — This   shows   the   extent   of  the   enlargement  of 
the  heart,  the  area  of  dulness  extending  farther  downward  and 
to  the  left  than  normal. 

AORTIC  STENOSIS. 

This  lesion  is  more  rare  in  children  than  in  adults,  being 
quite  infrequent  in  adults. 

There  is  a  narrowing  or  obstruction  of  the  orifice  of  the  aortic 
valve. 

Pathology. — As  in  the  mitral  stenosis  there  may  be  adhesions 
holding  the  valves  to  prevent  their  closure,  and  at  the  same  time 
obstructing  the  flow,  and  vegetations  may  narrow  the  opening. 
Congenital  narrowing  of  the  orifice  and  aorta  itself  may  rarely 
be  present.  From  overwork  in  forcing  blood  through  a  con- 
stricted opening,  the  left  ventricle  is  enlarged  and  hypertrophied. 
As  a  result  of  beginning  rupture  of  compensation  the  left 
auricle  becomes  enlarged  from  forcing  blood  into  a  partly  emptied 
ventricle. 

Symptoms. — As  a  rule  more  serious  symptoms  are  present  in 
this  form  of  valvular  lesion  than  any  other,  though,  as  in  the 
others,  no  symptoms  may  be  present.  With  beginning  rupture 
of  compensation  the  child  is  anemic,  incapable  of  the  least  exer- 
tion, either  mental  or  physical,  and  is  dyspneic. 

Mitral  regurgitation  frequently  occurs  as  a  complication  of 
aortic  stenosis. 

Physical  Signs. — Inspection. — Displacement  of  the  apex  beat 
downward  and  outward  owing  to  the  enlargement  of  the  left 
ventricle. 

Palpation. — A  systolic  thrill  may  be  felt  at  the  base,  along 
the  course  of  the  aorta  especially.  The  pulse  is  weak  because 
of  the  lessened  volume  of  blood  filling  the  artery.  The  artery 
does  not  fill  with  each  pulsation. 

Percussion. — This  only  confirms  the  enlargement  of  the  left 
ventricle  by  the  area  of  dulness  being  displaced  downward  and 
to  the  left. 

Auscultation. — Over  the  aortic,  or  second  right  interspace, 
there  is  a  systolic  murmur  heard  with  the  first  sound,  and  trans- 


446  THE  DISEASES  OF   CHILDREN, 

mitted  upward  in  the  great  vessels  of  the  neck.  It  may  follow 
the  blood  stream  down  the  aorta  and  be  heard  between  the 
scapulae. 

Prognosis. — Depends  on  the  amount  of  compensation  or  rup- 
ture of  compensatiop.  The  prognosis  is  serious.  Death  does 
not  occur  suddenly  in  this  form. 

TRICUSPID  REGURGITATION. 

This  is  the  principal  right  side  heart  lesion,  and  is  chiefly 
the  result  of  fetal  endocarditis. 

Pathology. — ^The  right  ventricle  and  auricle  are  enlarged  and 
the  walls  of  both  are  thinned.  There  are  usually  other  valvular 
lesions  associated  with  this  form. 

Symptoms. — Cyanosis  and  swelling  of  the  veins  of  the  face 
and  extremities  is  an  early  manifestation  of  this  damming  back 
of  the  venous  blood  current.  The  congestion  extends  to  the 
abdominal  viscera,  the  liver  and  the  hemorrhoidal  plexus  of 
veins  are  enlarged.  The  child  is  incapable  of  exertion,  and  when 
it  cries  there  is  an  evident  cyanosis.  Dropsy  of  the  extremities 
may  develop.     Hydrothorax  may  occur. 

Physical  Signs. — Inspection. — Enlargement  of  the  veins  of 
the  neck  are  quite  prominent,  and  in  the  event  of  ruptured  com- 
pensation jugular  pulsation  is  seen. 

Palpation. — The  venous  pulse  can  be  felt ;  also  one  in  the  liver 
if  this  organ  is  palpated. 

Percussion. — Increase  in  area  of  cardiac  dulness  to  the  right 
and  even  below  the  ensiform  cartilage. 

Auscultation. — A  blowing,  systolic  murmur  is  heard  best  over 
the  tricuspid  interspace,  second  left.  It  may  also  be  heard 
loudly  at  the  ensiform  cartilage. 

Prognosis. — This  is  relatively  grave,  more  so  if  associated 
with  lesions  at  other  orifices. 

TRICUSPID  STENOSIS. 

This  is  a  very  rare  and  practically  unknown  condition  in 
children.  Babcock  ^  refers  to  only  1154  cases  which  have  been 
recorded  in.  medical  literature. 


1  Babcock :    Diseases   of   the   Heart   and   Arterial    System. 


DISEASES   OF   THE    CIRCULATORY   SYSTEM,  447 

Pathology. — ^The  same  morbid  anatomy  exists  as  in  mitral 
stenosis. 

Etiology. — A  fetal  endocarditis  in  congenital  cases  and  rheu- 
matism in  those  developing  after  birth.  The  most  recorded 
cases  occur  between  20  and  30  years,  and  more  females  affected 
than  males. 

Symptoms. — The  majority  of  cases  evidently  go  unrecog- 
nized.    Visceral  engorgement  is  the  principal  manifestation. 

Physical  Signs. — Palpation  shows  the  pulse  weak  and  vari- 
able. 

Auscultation. — Like  the  other  physical  signs  the  sounds  are 
indefinite.  A  presystolic  murmur  may  be  heard  in  the  tricuspid 
area. 

Combined  Valvular  Lesions. — Any  two  or  several  of  the  val- 
vular lesions  described  may  be  associated  in  the  same  individual, 
as  mitral  stenosis  and  aortic  regurgitation ;  a  double  mitral  lesion ; 
mitral  and  aortic  stenosis,  etc. 

Prognosis  in  Valvular  Lesions. — As  noted,  there  is  usually 
no  immediate  danger  in  cases  of  valvular  lesions  in  children, 
but  because  of  the  secondary  symptoms  produced,  these  children 
do  not  do  well,  do  not  thrive.  Compensation  fails  sooner  or 
later  and  they  rarely  live  beyond  young  adult  life. 

The  Treatment  op  Valvular  Lesions. — The  physician  should 
have  control  of  the  child's  habits  of  life,  its  diet,  exercise,  cloth- 
ing and  sleep.  The  amount  allowed  of  each  depends  largely 
on  the  presence  or  absence  of  compensation.  If  compensation 
exists  the  whole  effort  of  treatment  is  to  maintain  it.  The  exer- 
cise must  be  under  supervision.  The  nurse  or  companion  should 
notice  carefully  for  over-fatigue,  symptoms  of  dyspnea  or  pallor, 
and  stop  violent  play  at  once.  Mitral  stenosis  demands  more 
care  than  any  of  the  rest.  Young  boys  should  be  warned  and, 
is  possible,  prevented  from  using  tobacco.  The  clothes  should 
be  prescribed,  not  too  light,  but  warm  and  protective.  Bathing 
to  obtain  an  active  skin  is  most  important.  The  diet  should  be 
so  regulated  that  no  residue  for  fermentation  is  left  in  the  bowel 
and  stomach.  Any  intercurrent  disease  must  receive  careful 
attention,  especially  epidemic  influenza  and  tonsillitis. 

Too  much  emphasis  cannot  be  placed  upon  the  importance  of 


448  THE  DISEASES   OF    CHILDREN. 

digitalis,  both  as  a  poison  and  a  drug  of  value.  Too  many 
physicians  use  this  drug  as  a  regular  and  routine  remedy,  no 
matter  whether  the  indication  is  present  or  not.  It  is  capable 
of  doing  great  injury,  and  should  be  used  only  when  a  positive 
indication  presents.  With  compensation  present,  digitalis  is 
not  indicated. 

Laxatives  should  be  used  when  indicated  and  the  formation 
of  toxines  and  intestinal  gases  prevented  if  possible. 

When  rupture  of  compensation  exists,  active  and  judicious 
treatment  is  indicated.  Every  condition  which  interferes  with 
proper  aeration  and  nutrition  should  be  removed.  If  adenoids 
are  present  they  should  be  removed,  if  a  gastric  catarrh  is  pres- 
ent it  should  receive  attention,  diet  should  be  so  regulated  that 
no  fermentation  takes  place. 

Digitalis,  in  the  presence  of  ruptured  compensation,  is  of 
great  value,  the  fat-free  preparation  being  prepared.  Strophan- 
thus  may  be  used  instead.  Strychnia  is  of  value  as  a  remedy 
and  its  effect  noted  carefully.  Its  cumulative  effect  has  been 
observed  with  muscular  twitchings  prominent. 

For  pain  in  the  primary  or  recurrent  endocardial  inflamma- 
tion, opium  in  some  form  is  indicated,  either  as  codeine  or 
heroin. 

Best  is  an  important  aid  in  the  treatment,  special  symptoms 
are  treated  as  they  arise. 

FUNCTIONAL  DISORDERS  OF  THE  HEART. 

Neuroses  of  the  heart  in  an  otherwise  normal  heart  are  not 
common  in  young  children.  The  two  conditions  most  often  met 
are  bradycardia  and  tachycardia. 

BRADYCARDIA. 

This  is  an  abnormally  slow  pulse  rate,  below  60  pulsations 
per  minute.  Very  rarely  the  pulse  may  be  found  normally  much 
slower  than  60.     Several  in  the  family  may  have  a  slow  pulse. 

Etiology. — Heredity  may  be  a  factor  in  its  causation.  It 
has  been  noticed  to  occur  in  masturbation  in  a  child.  It  may 
occur  during  the  course  of  or  convalescence  from  the  acute  infee- 


DISEASES  OP   THE   CIRCULATORY  SYSTEM.  .  449 

tious  diseases ;  diseases  of  the  gastroenteric  tract ;  in  degen- 
erative or  inflammatory  conditions  of  the  heart  muscle;  in 
uremia;  and  in  diseases  of  the  central  nervous  system. 

Symptoms. — No  special  symptoms  are  present  except  a  very 
slow  pulse.  There  may  be  a  disinclination  to  and  perhaps  an 
inability  for  violent  play  or  exercise. 

TACHYCARDIA. 

This  is  an  opposite  condition  from  bradycardia,  the  heart's 
action  being  very  rapid. 

Symptoms. — Apparently  without  cause  and  without  warning 
the  heart  begins  to  beat  very  rapidly,  tumultuously  and  irreg- 
ularly. The  pulse  is  accelerated  to  110,  or  not  quite  so  high, 
and  may  reach  140  or  150.  Palpitation  may  be  a  feature  of 
the  case,  and  oppression  of  breathing.  A  diagnosis  from  Graves' 
disease  must  be  made  in  all  cases. 

Treatment. — Removal  of  the  cause,  if  possible;  control  of  the 
diet  and  limitation  of  foods  which  ferment;  carefully  regulated 
exercise  and  regular  bathing. 

If  palpitation  is  a  feature,  morphine  will  be  of  most  benefit; 
the  bromides  may  control  the  attack;  nitroglycerine  is  given  in 
certain  cases;  aromatic  spirits  of  ammonia.  If  there  is  pain,  an 
ice  bag  can  be  applied  to  the  precordial  region. 

These  children  may  stand  the  strain  of  school  rather  badly, 
and  its  effect  should  be  carefully  noted  by  the  teacher. 

ACUTE  MYOCARDITIS. 

Definition. — This  is  an  inflammation  of  the  heart  muscle. 

Etiology. — It  may  occur  independently  of  endocarditis  or 
pericarditis,  but  secondary  to  infectious  or  septic  diseases, 
notably  diphtheria,  the  toxins  being  the  active  cause. 

Pathology. — The  muscle  of  the  thicker  ventricular  walls  is 
chiefly  involved,  and  the  process  has  been  described  as  paren- 
chymatous and  interstitial.  There  is  a  granular  degeneration 
of  the  muscle  fibers  which  are  soft  and  the  muscle  itself  flabby. 
Pus  may  be  found  in  the  muscle  wall  in  the  interstitial  form, 
this  form  occurring  as  a  sequel  to  pyemic  conditions. 


450  THE   DISEASES   OF    CHILDREN. 

Symptoms. — Occurring  as  myocarditis  does,  as  a  sequel  to 
infectious  diseases,  diphtheria  especially,  the  symptoms  appear 
as  convalescence  seems  established.  The  most  noticeable  con- 
dition is  a  weakening  of  the  heart's  action,  which  may  be  evi- 
denced by  the  character  of  the  pulse,  pallor,  apparent  shock 
and  inability  to  exercise  in  the  least.  The  pulse  is  accelerated, 
regular  as  to  time,  but  irregular  as  to  force  and  volume.  Be- 
cause of  the  feebleness  of  the  heart's  action,  there  is  no  apparent 
apex  beat,  and  the  sounds  are  indistinct  and  muffled.  Vomiting 
is  usually  present  and  in  connection  with  a  w'eak,  slow  or  irreg- 
ular pulse  is  not  a  good  sign.  Pain  in  the  precordial  region  may 
be  present. 

Prognosis. — Sudden  death  is  not  uncommon  in  these  cases. 
The  child  may  be  playing  about,  apparently  normal,  fall  and 
expire  in  a  remarkably  short  time.  The  pulse  returning  to  nor- 
mal is  the  best  sign  of  improvement.  A  very  slow  pulse  is  un- 
favorable. 

Treatment. — Prevention,  if  possible.  The  earlier  diphtheria 
antitoxin  is  used  the  less  chance  there  is  for  a  myocarditis  devel- 
oping. Absolute  rest  in  bed,  with  easily  digested  food.  Pain 
is  relieved  by  codeine  or  morphine,  strychnia  is  a  very  important 
adjuvant,  and  tonics  during  convalescence,  cod  liver  oil  and 
iron  especially. 


CHAPTER  XVIII. 

DISEASES  OF  THE  BLOOD. 

THE  BLOOD  OF  INFANCY  AND  CHILDHOOD. 

A  study  of  the  blood  is  a  most  important  diagnostic  aid  in 
many  febrile  and  other  conditions  in  infancy  and  childhood. 
An  examination  of  the  blood  is  proceeded  with  as  follows:  The 
lobe  of  the  ear  should  be  selected  for  the  puncture.  It  is  cleansed 
with  a  damp  sterile  or  clean  cloth  and  dried.  With  a 
triangular-pointed  needle,  lancet,  or  large  sewing-needle,  the 
skin  at  the  lower  edge  of  the  lobe  is  quickly  punctured.  The 
first  few  drops,  of  blood  are  wiped  off,  and  the  next 'can  be  used 
for  diagnostic  purposes.  If  to  be  examined  at  once,  with  a  cover- 
slip  touch  the  center  of  the  drop  of  blood  without  touching  the 
skin  and  drop  the  cover-face  down  on  a  clean  glass  slide. 
From  the  examination  of  this  slip  can  be  learned  whether  there 
are  any  plasmodium  malaria  or  the  blood  parasites;  relative 
number  of  white  cells,  number  and  character  of  the  red  blood 
cells,  and  whether  there  is  an  increase  in  the  ''blood  plates." 

Counting  the  blood  corpuscles  is  done  best  by  a  Thomas  Zeiss 
counter.  To  do  this,  the  blood  is  drawn  in  a  special  pipette, 
diluted  and  mixed,  placed  in  the  chamber  of  the  counting  slide 
and  the  corpuscles  counted.  If  the  distribution  of  the  cells  seems 
uniform  over  the  ruled  disc,  the  counting  is  begun.  An  objec- 
tive Leitz  5  or  Zeiss  D  and  a  No.  1  or  2  eyepiece  are  best  used. 
When  the  number  of  corpuscles  in  360  squares  has  been  counted 
the  number  must  be  divided  by  360,  and  multiplied  by  800,000, 
which  gives  the  number  of  corpuscles  in  1  cubic  millimeter. 
These  figures  and  the  amount  of  dilution  are  marked  on  the 
pipette. 

The  pipette  should  be  cleaned  and  dried  as  soon  as  the  count- 
ing has  been  completed. 

451 


452 


THE   DISEASES   OP    CHILDREN. 


In  counting  the  white  cells  the  "white  counter"  is  used,  and 
a  diluting  solution  Avhich  renders  the  red  cells  invisible. 

Hemoglobin  may  be  estimated  by  means  of  Dare's,  Tallquist's, 
Oliver's  or   Von   Fleischl's  hemoglobinometer.      Tl^    Tallquist 


Fig.    81. — Tallquist   hemoglobin   scale. 

0'     •  ■  i 


Fig.    82. — Dare's    hemoglobinometer. 

scale  is  used  by  soaking  into  standard  filter  paper  a  drop  of 
blood  and  comparing  it  with  a  water-color  scale  of  10  tints,  and 
is  accurate  enough  for  bedside  test,  an  error  of  not  more  than  10 
per  cent  being  made. 

Oliver's  instrument  consists  of  a  series  of  12  tinted-glass  discs 
arranged  in  two  rows,  the  color  scheme  corresponding  to  hemo- 
globin percentages  of  from  10  to  120. 

Von  Fleischl's  instrument,  the  cell  holding  the  diluted  blood, 


DISEASES   OF   THE   BLOOD.  453 

has  a  moving  color  scale  underneath,  with  reflected  light  shining 
through  it.  The  scale  is  moved  back  and  forth  until  the  color 
of  the  glass  is  the  same  as  the  blood.  The  percentage  of  hem- 
oglobin is  given  on  the  scale. 

At,  birth  the  hemoglobin  percentage  is  high,  usually  100,  but 
after  a  month  or  so  decreases  to  60  or  80. 

The  color  index  of  a  specimen  of  blood  is  obtained  by  dividing 
the  per  cent  of  hemoglobin  by  the  per  cent  of  red  blood  cells. 

Red  Blood  Corpuscles. — The  blood  being  spread  thickly 
shows  the  red  cells  in  rouleaux,  hence  thin  spreads  must  be  made 
if  the  cells  are  to  be  examined.  They  are  round,  biconcave  discs, 
varying  little  in  size  in  health,  averaging  about  7.5  fi. 

In  disease  the  red  cells  may  be  very  small,  2  /x  to  4  /*,  micro- 
cytes,  or  they  may  be  very  large,  10  /a  or  even  20  fi,  megalocytes, 
when  misshapen  they  are  called  poikilocytes. 

During  fetal  life  nucleated  red  cells  are  found,  but  they  dis- 
appear as  the  number  of  red  cells  decrease  and  only  recur  as  a 
result  of  disease.  The  nucleated  red  cells  are  divided  into. the 
normohlasts,  an  immature  red  cell,  the  nucleus  staining  very 
dark.     It  is  found  in  severe  anemias,  chlorosis,  etc. 

The  megalohlast  is  a  very  large  cell  (11  to  20  fi)  with  large 
nucleus,  and  occurs  in  certain  grave  forms  of  anemia.  Its  pro- 
toplasm stains  irregularly.  The  microhlasts  are  much  rarer 
than  either  of  the  other. 

The  number  of  red  blood  cells  (erythrocytes)  is  greater  during 
the  first  forty-eight  hours  after  birth,  Hayem  placing  the  num- 
ber at  5,900,000,  gradually  lessening  in  number  to  4,500,000  at 
the  end  of  the  first  week. 

White  Blood  Corpuscles. — The  following  varieties  of  white 
corpuscles  are  recognized: 

1.  Polymorphonuclear  neutrophilic  leucocytes  or  the  polynu- 
clear  leucocytes. — These  cells  comprise  most  of  the  white  blood 
corpuscles,  and  are  those  found  in  pus.  They  are  irregular  in 
shape  and  none  are  exactly  alike,  and  stain  deeply  with  basic 
dyes.  Stained  with  Wright's  stain  the  nucleus  takes  on  a  deep 
blue  color,  the  protoplasm  pink.     Their  size  is  13.5  fx. 

2.  Lymphocytes. — These  are  referred  to  as  lymphocytes  and 
large  mononuclear  cells.     The  lymphocyte  varies  in  size  from 


454  THE  DISEASES  OP   CHILDREN. 

size  of  red  cell  to  larger,  and  has  a  nucleus  which  stains  deep 
blue.  The  larger  cells  are  much  larger  than  the  lymphocytes 
and  have  an  oval  nucleus.     The  large  cell  is  13  fi,  the  small  10  /x. 

3.  EosinopKiles. — These  cells  are  polymorphous.  The  gran- 
ules are  1  /i,  in  diameter.  They  take  the  Wright  stain,  the  nu- 
cleus stains  lilac,  the  granules  a  bright  pink,  and  the  protoplasm 
a  pale  blue. 

4.  Mast  Cells. — These  stain  with  Wright's  stain.  They  are 
twice  the  diameter  of  the  red  cell.     They  are  15  /a  in  size. 

The  frequency  of  the  various  white  cells  is  given  as  follows: 

Adults  2 
Infants  ^  Per  cent. 

Lymphocytes    40  to  60  20  to  30 

Large  mononuclears 4  to  5 

Polynuclears    18  to  40             62  to  70 

Eosinophiles     2  to     4               ^  to  4 

Mast   cells    1/40  to  * 

Myelocyte. — This  cell  is  found  normally  in  the  bone  marrow, 
and  is  found  in  the  blood  stream  only  under  abnormal  condi- 
tions, as  in  diphtheria.  It  stains  best  with  Ehrlich's  stain.  It 
has  a  large  number  of  granules,  and  they  take  the  acid  dyes. 

They  are  15.75  /x  in  size. 

Deg'enerated  Leucocytes,  which  are  chiefly  degenerated 
lymphocytes  and  large  mononuclear  lymphocytes. 

Number  of  Leucocytes. — In  the  blood  in  infancy  the  number 
of  leucocytes  is  greater  than  in  adults.  At  birth  they  niay 
reach  20,000  to  25,000.  In  a  week  or  so  the  number  falls  to 
9,000  to  15,000,  and  later  in  childhood  they  are  still  fewer  in 
number,  7,000  to  10,000.  After  the  third  year  they  will  average 
8,000. 

General  Consideration  of  Blood  Changes. — The  examination 
of  the  blood  should  be  considered  in  the  light  of  a  clinical  phe- 
nomenon. Stained  smears  show  the  relative  number  of  white 
and  red  corpuscles,  and  to  the  trained  eye  this  is  often  equiv- 
alent to  a  differential  count.  The  stain  also  sliows  the  Plas- 
modia malaria,  filaria  and  otlier  blood  parasites,  as  well  as  the 
character  of  the  red  cells. 


^Carr:   Practice   of    Pediatries.  -Cabot. 


DISEASES   OP   THE   BLOOD.  455 

There  may  be  a  decrease  in  the  number  of  red  blood  cells, 
as  in  the  anemias.  There  is  a  temporary  increase  in  their  num- 
ber in  cyanosis. 

Physiologically  there  may  be  an  increase  in  the  number  of 
the  white  blood  cells.  This  occurs  normally  after  digestion, 
exercise  and  cold  baths.  A  transitory  increase  is  termed  leuco- 
cytosis.  The  term  relative  leucocytosis  is  used  when  there  is 
an  increase  in  any  type  of  leucocyte,  as  lymphocytosis,  occur- 
ring in  congenital  syphilis  and  scorbutus ;  eosinophilia,  occurring 
in  lukemia;  neutrophilic  leucocytosis. 

Leucocytosis,  as  stated,  is  the  rule  in  the  blood  of  infants  and 
occurs  as  a  result  of  intestinal  disorders,  congenital  heart  dis- 
ease, rachitis,  chronic  tuberculosis,  toxemias,  diphtheria,  syph- 
ilis, pertussis,  pus  conditions,  etc. 

Leucopenia  is  used  to  describe  a  decrease  in  the  total  number 
of  leucocytes.  It  occurs  in  malaria,  measles,  influenza,  gastro- 
intestinal  troubles  of  inflammatory  type,   etc. 

ANEMIA. 

It  must  be  borne  in  mind  in  the  examination  of  the  blood  of 
infants,  the  normal  tendency  to  a  lymphocytosis  and  the  lower 
hemoglobin  percentage,  when  compared  with  adults. 

In  anemia  there  is  a  deficiency  in  the  red  blood  corpuscles 
and  a  decrease  in  hemoglobin,  the  coloring  matter  of  the  red 
cells.  With  these  changes  there  may  be  a  decrease  in  the  total 
volume  of  blood.  The  anemias  are  classified  as  primary  and 
secondary. 

Primary  Anemia. — Definition. — By  this  form  is  generally 
understood  the  anemias,  the  cause  of  which  is  unknown,  as  per- 
nicious anemia,  there  being  a  grave  blood  condition,  enough  to 
cause  death,  yet  the  underlying  cause  not  known,  and  chlorosis. 

Secondary  Anemia. — Definition.^ — This  can  be  described  as 
a  symptomatic  (Cabot)  anemia,  the  blood  changes  being  due 
to  certain  conditions  which  are  more  or  less  well  known,  as  hem- 
orrhage, malaria,  syphilis,  tuberculosis,  gastrointestinal  disease, 
scorbutus,  rachitis,  etc. 

In  the  secondary  form  of  anemia  there  is  a  diminution  in  the 
coloring  matter,  the  number  of  cells  remaining  near  normal. 


456  THE   DISEASES   OF    CHILDREN. 

It  presents  in  the  form  in  which  the  red  cell  is  deformed,  pot- 
kilocytosis;  they  may  change  as  regards  their  staining  qualities ; 
the  formation  of  nucleated  red  cells,  the  normoblasts,  megalo- 
hlasts  and  microhlasts. 

PERNICIOUS  ANEMIA. 

Synonyms. — Progressive  pernicious  anemia;  anemia  infantum. 

Definition. — ^This  is  the  form  of  anemia  which  is  generally 
fatal,  and  presents  a  definite  blood  picture  without  apparent 
cause.     It  is  comparatively  rare  in  infants. 

Etiology. — ^This  is  not  known,  save  that  the  so-called  simple 
secondary  anemias  have  been  known  to  develop  into  the  perni- 
cious form.  The  ankylostoma  duodenale  has  been  given  as  a 
cause  in  the  South.  It  has  been  estimated  ^  as  occurring  in 
about  2  per  cent  of  all  internal  diseases.  It  occurs  slightly 
more  often  in  males  and  with  great  rarity  under  five  years  of 
age.  Rotch  did  not  find  a  single  case  in  2000  cases  of  children's 
disease  in  the  Children's  Hospital  of  Boston.  Stengel  believes 
the  bothriocephalus  may  produce  this  form. 

Pathology. — The  anemia,  pallor  and  the  extravasations  of 
blood  into  and  the  fatty  degeneration  of  the  internal  organs  is 
noticeable  at  once.  Free  iron  is  found  in  the  internal  organs, 
especially  the  liver.  The  chief  pathologic  changes  are  in  the 
heart.  The  central  nervous  system  and  cord  show  the  same 
hemorrhagic  condition  as  the  other  organs  in  addition  to  anemia. 

The  hone  mxirrow  in  this  disease  differs  from  the  normal  in 
that  there  is  a  large  increase  in  the  megaloblasts. 

The  red  cells  are  markedly  decreased,  averaging  from  1,500,- 
000  to  1,000,000.  The  hemoglobin  is  usually  decreased,  but  not 
in  proportion  to  the  reduction  in  red  cells,  but  the  opposite  may 
as  frequently  be  seen,  viz.,  a  relatively  high  hemoglobin,  consid- 
ering the  diminution  in  red  cells.  The  amount  of  blood  is  usu- 
ally reduced  and  coagulation  in  fresh  blood  is  much  slower.  The 
fresh  blood  looks  pale  in  color.  The  number  of  leucocj^tes  is 
also  reduced.  The  blood  does  not  show  the  usual  rouleaux  for- 
mation.    The  oval-shaped  red  cells  may  predominate. 

Symptoms. — The  onset  of  pernicious  anemia  is  insidious.     It 

^  Lazarus ;    Nothnagle :   Diseases  of  Blood. 


DISEASES   OP   THE   BLOOD.  457 

may  at  first  be  diagnosed  as  a  simple  anemia  with  gradually 
increasing  debility  and  lack  of  energy,  with  decreased  endurance. 
Pallor  of  the  skin  followed  by  a  distinct  lemon-yellow  color, 
develops  very  soon.  Anemia  of  the  mucous  membrane  follows; 
there  is  dyspnea,  anorexia,  perhaps  nausea  and  vomiting,  loss  of 
flesh  and  edema.  Palpitation  is  frequent  on  the  least  exertion 
or  excitement.  Small  hemorrhages  may  occur  in  the  conjunctiva 
and  the  skin.  Hemic  murmurs  are  frequent.  Frequently  dis- 
tinct remissions  occur,  when  there  is  an  apparent  improvement 
in  all  the  symptoms. 

There  is  an  increase  in  the  number  of  the  red  cells,  approach- 
ing normal,  a  decrease  in  the  megaloblasts  and  increase  in  the 
normoblasts.  There  is  an  increase  in  the  leucocytes,  mostly 
the  polymorphonuclear  neutrophiles. 

The  digestive  symptoms  are  improved  and  the  palpitation 
lessened  or  absent  entirely. 

These  remissions  may  be  permanent,  the  case  progressing  to 
complete  recovery,  when  apparently  hopeless  before,  or  go  on 
to  a  fatal  termination  after  a  very  short  period  of  r-emission. 

The  course  of  the  disease  is  variable,  usually  under  a  year. 

Diagnosis. — The  general  appearance  of  the  patient  is  always 
suggestive  of  the  form  of  anemia  present.  In  no  other  form  is 
the  pallor  or  anemia  as  intense,  but  without  careful  and  repeated 
blood  examination  a  diagnosis  is  not  justified.  The  group  of 
symptoms  enumerated  above,  with  the  characteristic  blood  find- 
ings, makes  a  diagnosis  certain.  These  important  changes  are 
a  marked  decrease  in  the  red  cells,  to  1,500,000  or  below,  and 
an  increase  in  their  size;  diminished  number  of  white  cells; 
slight  relative  decrease  in  hemoglobin;  presence  of  megaloblasts 
in  increased  numbers. 

Prognosis  is  graver,  though  apparently  hopeless  cases  have 
recovered  after  a  period  of  remission.  If  it  is  a  bothriocephalus 
anemia,  and  the  anemia  improves,  the  prognosis  is  very  good. 
The  nearer  the  red  cells  decrease  to  1,000,000  the  graver  the 
prognosis. 

Treatment. — The  removal  of  the  bothriocephalus  latus,  if  it 
or  its  eggs  can  be  demonstrated,  is  the  first  indication.  Felix 
mas  is  perhaps  the  most  efficacious  anthelmintic  for  this  worm. 


458  THE  DISEASES  OP    CHILDREN. 

Special  attention  should  be  given  the  stomach  and  intestine 
by  regulating  the  diet,  controlling  diarrhea,  if  present,  and  the 
administration  of  remedies  to  limit  the  fermentation,  bismuth 
and  salol  are  especially  efficacious.  Constipation,  if  present, 
ca^  be  controlled  by  enemata. 

Arsenic  is  the  remedy  which  gives  the  best  results.  It  should 
be  given  in  small  initial  doses,  gradually  increasing  until  the 
full  physiologic  effects  have  been  noticed.  The  dose  should  then 
be  decreased  20  per  cent,  and  its  administration  continued  for 
several  weeks  at  that  dose.  Fowler's  solution  is  the  best  form 
for  administration. 

The  employment  of  direct  transfusion  of  blood  offers  much, 
and  should  be  used  when  possible. 

The  patient  should  be  given  every  opportunity  to  rally  as 
regards  his  surroundings,  climate,  rest,  freedom  from  work  and 
worry,  and  during  a  remission  extra  precautions  taken  in  these 
details. 

CHLOROSIS. 

Definition. — A  primary  anemia  which  occurs  in  girls  about 
the  age  of  puberty.  There  is  an  anemia,  with  diminished, 
though  not  a  marked  increase  in  the  number  of  red  cells  and  a 
lowered  hemoglobin  percentage. 

Etiology. — It  can  be  said  practically  that  chlorosis  occurs 
only  in  girls,  and  it  is  most  frequent  at  puberty,  from  the  twelfth 
to  the  eighteenth  year.  Often  a  history  of  chlorosis  in  the 
mother,  or  members  of  her  family,  can  be  brought  out,  or  a 
tuberculosis  in  the  famity.  A  chronic  intestinal  indigestion 
and  putrefaction,  causing  an  autointoxication,  may  be  a  cause. 
Bad  hygienic  surroundings  in  factories  and  in  crowded  dormi- 
tories with  insufficient  ventilation  may  be  a  predisposing  cause. 
Constipation,  improper  food,  lack  of  proper  exercise  and  tight 
lacing  and  the  changes  incident  to  puberty  are  given  as  causes. 

Pathology. — The  chief  changes  occurring  in  the  blood  are  as 
follows:  The  hcmogJohin  is  reduced  to  a  decided  extent,  reach- 
ing as  low,  in  some  isolated  cases,  as  20  per  cent,  the  average 
being  about  40  per  cent;  the  number  of  red  cells  are  reduced, 
but  not  to  the  same  extent  as  indicated  by  the  reduction  of  the 
hemoglobin.     The  average  number  of  red  cells  is  about  4,000,- 


DISEASES  OP   THE   BLOOD.  459 

000.  They  are  pale,  not  Reformed,  but  apt  to  be  smaller  than 
normal.     Poikilocytosis  is  present  in  severe  cases. 

The  white  cells  may  be  normal  in  number. 

The  specific  gravity  of  the  blood  is  reduced. 

Symptoms. — The  first  symptom  noted  may  be  a  disinclina- 
tion to  exercise  in  a  previously  active  girl,  palpitation,  short 
quick  breathing  or  dyspnea,  on  going  up  the  steps,  dizziness,  fol- 
lowed in  a  varying  time  by  pallor  of  the  skin  and  mucous  mem- 
branes, the  skin  having  frequently  a  greenish  tinge. 

The  changes  in  menstruation  are  more  or  less  constant ;  in  the 
majority  of  cases  it  is  absent  entirely,  if  present  it  is  very  irreg- 
ular as  to  time  and  quantity  and  color  of  the  flow.  This  irregu- 
larity of  menstruation  may  be  the  first  symptom  noted.  Pain 
before  or  early  in  the  stage  of  flow  may  develop.  Leucorrhea 
is  very  often  present.  The  appetite  is  poor  and  often  capricious, 
craving  for  acids  is  often  a  feature.  Headaches  are  common, 
and  are  often  associated  with  ringing  in  the  ears.  The  circula- 
tion is  poor,  hands  and  feet  cold.  Blowing  systolic  murmurs  are 
often  heard,  at  various  parts  of  the  precordia,  and  a  venous 
hum,  the  bruit  de  diahle,  develops  over  the  large  vessels  in  the 
neck. 

No  great  changes  are  found  in  the  urine.  There  may  be  an 
increase  with  low  specific  gravity.  The  spleen  may  be  enlarged, 
but  not  markedly  so.  Hysteria,  or  milder  form  of  irritability, 
may  be  seen  in  the  specially  neurotic  girl.  The  duration  is  vari- 
able, usually,  however,  running  for  several  weeks. 

Diagnosis. — The  principal  diagnostic  features  are  the  sex, 
age,  anemia  and  blood  findings,  viz.,  marked  diminution  in  hemo- 
globin, without  corresponding  diminution  in  the  number  of  red 
cells,  rapid  improvement  under  proper  treatment.  In  making 
a  diagnosis  tuberculosis  will  have  to  be  excluded. 

Prognosis. — Influenced  greatly  by  the  period  of  recognition 
and  time  of  beginning  and  persistence  in  treatment. 

Treatment. — All  girls  at  puberty  should  receive  careful  at- 
tention. Rest  at  menstrual  epochs,  and  carefully  regulated  diet 
and  exercise  is  very  important.  The  articles  of  diet  specially 
indicated  are  the  fats,  vegetables  and  fruits.  Those  vegetables 
containing  a  large  supply  of  iron  are  best,  as  the  green  vege- 


460  THE   DISEASES   OF    CHILDREN. 

tables,  spinach,  etc.  A  change  from  the  city  to  the  country  is 
also  of  great  benefit  as  a  prophylactic. 

At  the  first  sign  of  anemia  or  the  preliminary  symptoms  of 
chlorosis  the  girl  should  be  taken  from  school,  or  a  very  care- 
fully graded  course  outlined  in  connection  with  baths,  diet,  ex- 
ercise and  regulation  of  the  bowels.  The  medicinal  treatment 
is  largely  symptomatic,  except  the  positive  indication  for  the 
administration  of  iron. 

The  bowels  must  be  regulated  by  mild  laxatives,  cascara  sa- 
grada,  aloin,  belladonna  and  strychnia,  etc.,  and  other  symp- 
toms treated  as  they  arise. 

Iron  must  be  given  in  some  form ;  metallic  iron ;  ferrous  and 
ferric  salts;  albuminates  and  peptonates;  nucleoalbumin  prepa- 
rations. 

Diastiron  is  very  assimilable  and  easily  taken  care  of  by  most 
children.  It  can  be  given  in  a  half  to  one  teaspoonful,  initial 
dose,  gradually  increased  to  two  teaspoonfuls. 

Pil  Blaud,  5  grains,  is  an  excellent  method  of  administration 
of  iron,  beginning  with  one  after  each  meal,  gradually  increasing 
during  the  second  week  to  two  after  each  meal,  then  decreasing 
to  the  original  dose  after  a  week.  The  following  prescriptions 
are  often  found  of  service: 

IJ  Tincture   ferri   chloridi     f.^ss 

Acidi  phosphorici  diluti   f.3vi 

Spiritus  limonis  f.Sii 

Syrupi  simplicis  q.s.  ad  f.5vi 

M.  Sig.     Dessertspoonful  in  water  after  eating. 

IJ  Acidi   phosphor,   dil. 
Acidi  nitro-mur.  dil. 
Acidi  sulphurici  aromat. 
Tr.  ferri  chloridi         aa  f.^ss 
M.  Sig.     Twenty  drops  in  half  glass  of  water. 

Iron  should  not  be  continued  indefinitely,  nor  should  it  be 
given  when  no  improvement  in  general  symptoms  or  hemo- 
globin has  been  obtained  in  a  short  time,  or  when  it  produces 
decidedly  bad  symptoms  with  the  digestive  organs.  One  remedy 
which  can  be  used  to  advantage  in  chlorosis  is  arsenic.  The 
following  pill  is  of  service: 


DISEASES   OP    THE   BLOOD.  461 


Sig. 


IJ  Ferri  reducti 

gr.  Ixxv 

Acidi   arseniosi 

gr.  iii  • 

Ext.    glycyrrhizae 

q.   s. 

M.  et  ft.  pil  No.  C 

One  to  four  pills  daily. 

(V.  Noorden) 

LYMPHATIC  LEUKEMIA. 


Definition. — In  this  disease  the  characteristic  symptom  is  a 
great  increase  in  the  number  of  leucocytes,  with  an  increase  in 
size  of  those  organs  specially  associated  with  blood-making, 
spleen  and  glands. 

Two  forms  are  recognized,  the  acute,  in  which  there  is  a  rapid 
and  fatal  termination  in  a  few  weeks,  and  the  chronic,  which 
may  continue  for  months. 

The  Acute  Form.  Etiology. — Two  types  are  recognized,  the 
myeloid,  in  which  there  is  great  hypertrophy  of  the  spleen  and 
bone-marrow  changes,  and  but  little  lymphatic  enlargement,  or 
the  lymphoid,  in  which  there  is  generally  a  hyperplasia  of  the 
lymph  nodes,  and  in  which  the  blood  shows  particularly  the 
lymphocytes. 

Leukemia  may  occur  at  any  age.  Heredity  is  a  causative 
factor.  Among  the  other  predisposing  causes  may  be  men- 
tioned intestinal  intoxication ;  poor  surroundings  and  hygiene ; 
malaria ;  syphilis ;  tuberculosis ;  influenza  and  rachitis. 

Pathology.  The  Myeloid  Form. — ^The  essential  changes  are 
in  the  blood,  bone  marrow  and  spleen.  The  red  cells  are  slightly 
diminished  in  number,  averaging  about  3,500,000.  The  hemo- 
globin is  diminished  probably  to  50.  The  red  cells  show  many 
nucleated  forms.  The  typical  changes  in  the  blood  are  in  the 
white  blood  corpuscles.  The  leucocytes  are  greatly  increased 
in  number,  varying  from  100,000  to  300,000,  though  there  may 
be  a  far  greater  increase. 

The  myelocytes  are  greatly  increased  in  number.  They  may 
comprise  more  than  one-third  of  the  number  of  cells,  and  from 
this  feature  alone  the  diagnosis  can  be  made.  Polymorphonu- 
clear cells  are  slightly  increased  in  number,  both  large  and 
small,  with  nuclei  staining  differently.  Lymphocytes  are 
decreased  quite  decidedly,  but  not  as  much  so  as  the  myelocyte. 

The  glands  show  cell  proliferation  and  enlargement. 


462  THE   DISEASES   OF    CHILDREN.     " 

Hemorrhages  are  of  frequent  occurrence,  both  on  mucous  sur- 
faces and  skin,  and  ulceration  takes  place  in  these  areas.  They 
may  occur  in  the  glands  also. 

The  bone  marrow  is  changed  from  the  normal  fat  marrow  to 
a  dark,  wine-colored,  soft  marrow. 

Lymphatic  deposit  occurs  in  the  spleen,  liver,  kidneys,  esoph- 
agus, stomach  and  intestine,  tonsils  and  thymus,  all  of  which 
show  enlargement  or  thickening. 

Symptoms. — The  course  of  acute  leukemia  is  short,  from  a 
few  days  to  several  weeks,  rarely  lasting  months.  The  onset  is 
usually  insidious,  but  it  may  be  sudden,  or  at  least  few  symp- 
toms are  present  while  the  preliminary  blood  changes  are  occur- 
ring, which  the  patient  will  complain  of. 

Lassitude,  weakness,  dizziness,  headache,  may  precede  the  act- 
ual symptoms.  This  is  followed  by  pallor  of  the  skin  and  mu- 
cous membranes,  and  shortly  by  enlargement  of  the  lymph 
nodes,  spleen  and  tonsils.  The  spleen,  when  enlarged,  is  pal- 
pable. Hemorrhages  occur  in  the  skin,  mucous  membrane  and 
in  the  eye.  The  hemorrhages  in  the  skin  may  be  simply  petechia 
or  large  bruise-like  areas.  These  also  occur  in  the  mucous 
membrane  of  the  mouth,  gums  and  palate.  Nasal  hemorrhages 
may  occur.  Necroses  may  develop  at  the  site  of  these  hemor- 
rhagic areas.  Hematemesis  and  hemorrhage  from  the  bowel 
may  be  seen,  and  these  active  hemorrhages  may  cause  death. 

Diagnosis. — The  blood  changes  are  typical  of  the  disease. 
In  no  other  condition  is  a  lymphocytosis  so  marked. 

Prognosis. — This  is  unusually  grave.  Hemorrhages  and  sep- 
tic infection  at  the  site  of  necrosis  may  hasten  the  end. 

Treatment  is  of  little  avail  and  is  largely  symptomatic. 
Good  food,  stimulation  when  indicated,  fresh  air,  the  best  sur- 
rovindings  and  administration  of  iron. 

The  Chronic  Form. — In  this  class  are  included  those  rare 
forms  in  which  the  duration  is  longer  than  a  few  weeks.  They 
present  the  same  general  symptoms  and  blood  findings. 

Etiology. — Nothing  definite  is  known  of  the  etiology  of  this 
or  the  myelogenous  form  of  leukemia ;  of  late  some  interesting 
suggestions  have  been  made  that  it  is  probably  the  result  of  an 
infection. 


DISEASES   OF   THE   BLOOD,  463 

Pathology. — The  chief  change  is  in  the  lymph  nodes.  The 
glands  of  the  neck  and  thorax  are  principally  enlarged.  They 
may  be  soft  and  tender.  The  spleen  is  enlarged,  in  some  cases 
to  a  considerable  size.  The  bone  marrow  is  reddish  in  color  and 
of  jelly-like  consistency.  The  liver  is  enlarged,  as  are  the  ton- 
sils. Tumors  form  in  the  skin,  generally  quite  small  and  shot- 
like, but  they  may  enlarge  to  considerable  size. 

Symptoms. — The  onset  is  usually  gradual.  It  is  often 
chronic  in  form.  The  anemia  may  precede  the  enlargement  of 
the  lymph  nodes  or  rice  versa.  The  glands  of  the  neck  usually 
show  the  greatest  proliferation  and  enlargement,  with  smaller 
ones  in  the  axilla  and  groin.  It  may  be  possible  to  palpate  the 
mesenteric  glands.  The  spleen  regularly  shows  an  enlargement, 
sometimes  to  enormous  proportions. 

The  blood  shows  a  lympJiocytosis.  Of  the  increase  in  leu- 
cocytes, 90  per  cent  of  them  will  be  lymphocytes.  The  average 
ratio  of  white  to  red  cells  is  about  1 :50.  The  lymphocytes  are 
usually  of  the  small  variety,  under  10  ix  in  diameter,  in  the 
chronic  form,  and  larger  in  the  acute  form.  The  red  cells  are 
reduced  to  3,500,000,  or  lower,  and  the  white  cells,  300,000. 
Eosinophiles  or  myelocytes  are  very  scanty  or  absent.  Hemo- 
globin is  decreased. 

Hemorrhages  are  infrequent. 

Dyspnea  is  a  frequent  and  early  symptom,  which  is  due 
partly  to  blood  changes,  and  chiefly  to  obstruction  from  enlarged 
lymph  nodes. 

Diagnosis. — The  presence  of  the  lymphocytosis  is  the  chief 
diagnostic  sign.  In  the  presence  of  anemia,  enlargement  of 
lymph  nodes  and  spleen,  the  blood  should  always  be  examined. 

Prognosis. — The  progress  of  this  disease  is  toward  a  fatal 
termination,  though  it  may  last  for  months. 

Treatment. — Practically  nothing  can  be  done  in  this  form, 
as  in  the  myeloid  form,  except  to  care  for  the  case  systematically. 

If  symptoms  from  the  glandular  enlargement  in  the  neck  are 
present,  surgery  is  indicated  for  relief,  if  the  general  condition 
is  fairly  good.  Arsenic  is  indicated  and  should  be  given  as  early 
as  possible. 


464  THE   DISEASES   OF    CHILDREN. 

PSEUDOLEUKEMIA. 

Sjmonyms. — Hodgkin's  disease;  lymphoma. 

Definition. — This  is  a  primary  disease  of  the  lymph  struc- 
tures. There  is  an  enlargement  of  the  lymph  glands  and  spleen, 
much  as  in  lymphatic  leukemia,  but  without  the  blood  changes 
in  the  latter. 

Pathology. — Early  in  the  disease  the  blood  may  be  normal, 
but  the  hemoglobin  decreases  as  it  progresses,  and  there  is  a  de- 
cided anemia.  At  first  there  may  be  no  change  in  the  white 
cells,  but  later  there  is  a  marked  increase  in  the  white  cells,  a 
ratio  being  sometimes  seen  (in  the  presence  of  adenitis)  of  1 :80 
when  compared  to  the  red  cells.  The  increase  is  chiefly  in  the 
lymphocytes. 

The  red  cells  are  progressively  diminished  in  number. 

Symptoms. — ^The  chief  symptoms  are  those  pointing  to  the 
lymph  glands.  These  may  be  hard  or  soft.  The  spleen  is  reg- 
ularly found  enlarged.  The  glands  of  the  neck  show  the  great- 
est enlargement.  With  the  progress  of  the  anemia  the 
constitutional  symptoms  develop,  weakness,  dizziness,  fainting, 
palpitation,  etc.  Skin  tumors  develop  as  in  lymphatic  leuke- 
mia. Its  course  is  slow  and  death  may  occur  from  pressure  on 
the  vessels  of  the  neck  and  on  the  trachea  and  bronchi. 

Diagnosis. — The  enlargement  of  the  lymph  nodes,  with  blood 
changes,  showing  lymphocytosis,  a  relative  increase  of  1 :200 
ratio  of  white  to  red.  The  diagnosis  must  be  made  from  a 
glandular  tiiberaidosis,  in  which  there  will  not  be  any  of  the 
typical  blood  changes,  and  from  lymphosarcoma,  in  which  the 
lymph  glands  show  malignant  change  and  the  blood  changes  are 
not  those  of  pseudoleukemia. 

Prognosis. — Death  is  not  as  prompt  as  in  leukemia,  but  just 
as  certain  in  time.     There  is  no  cure. 

Treatment. — Apparent  improvement  has  been  reported  from 
the  use  of  arsenic  and  the  iodides.  Surgery  is  not  to  be  rec- 
ommended. In  the  large  growths  about  the  neck,  some  good  may 
be  accomplished  by  the  use  of  the  X-ray. 

PSEUDOLEUKEMIA  OF  INFANTS. 

Synonyms. — Anemia  pseudoleukemic  infantum  {v.  Jaksch) ; 
pseudopernicious  anemia  (Ehrlich). 


DISEASES   OP   THE   BLOOD.  465 

Definition. — This  is  a  grave  form  of  anemia,  first  described 
by  V.  Jaksch  in  1889.  There  is  a  severe  anemia,  leucocytosis 
and  enlargement  of  the  lymph  nodes,  spleen  and  tonsils. 

Etiology. — It  may  occur  independently  or  develop  from  some 
of  the  grave  anemias.  11  occurs  between  the  seventh  and  ninth 
month  and  the  fourth  year.  Congenital  syphilis  is  a  predis- 
posing cause. 

Pathology. — The  chief  change  is  an  enlargement  to  consid- 
erable size  of  the  spleen,  which  can  be  seen  through  the  abdom- 
inal wall.  It  is  hard  to  the  feel.  The  liver  is  slightly  but  not 
markedly  enlarged.  The  lymph  nodes  are  quite  regularly  en- 
larged, but  not  to  the  size  seen  in  typical  pseudoleukemia. 

The  dlood  sho"Ws  a  marked  diminution  in  the  hemoglobin, 
often  considerably  below  50.  There  is  a  regular  decrease  in  the 
red  blood  cells,  to  2,000,000  or  below.  Nucleated  red  cells  are 
found,  megaloblasts  and  normoblasts. 

The  white  cells  are  increased,  myelocytes  are  found.  They 
stain  irregularly. 

Symptoms. — There  are  no  typical  symptoms.  Those  com- 
mon to  the  other  types  of  anemia  are  present.  There  is  gener- 
ally a  loss  of  appetite;  enlargement  of  glands  and  spleen;  ema- 
ciation, with  a  tendency  to  develop  into  a  chronic  condition. 
Syphilis  may  be  suspected  instead  of  the  anemia. 

Treatment. — The  administration  of  iron  and  arsenic  and  the 
careful  regulation  of  the  feeding  are  the  most  important  indi- 
cations to  be  met. 

In  older  children  a  rich  proteid  diet  is  best;  meat,  eggs  and 
milk ;  in  the  younger  a  fat  increase  should  be  made  and  continued 
as  long  as  well  borne. 

PURPURA. 

Definition. — This  is  a  condition  characterized  by  hemor- 
rhages occurring  under  the  skin  and  from  the  mucous  mem- 
branes. 

Etiology. — It  is  divided  into  two  varieties,  purpura  simplex, 
the  bleeding  being  limited  to  the  skin,  and  purpura  hemor- 
rhagica, where  there  are  also  hemorrhages  into  the  internal  or- 
gans and  from  the  mucous  membranes. 


466  THE  DISEASES  OF   CHILDREN. 

It  may  be  due  to  septic  conditions  and  the  infectious  dis- 
eases, as  septic  endocarditis  and  the  exanthemata;  as  a  result 
of  exhausting  diseases,  as  bronchopneumonia,  pertussis,  typhoid 
fever,  ileocolitis,  tuberculosis;  from  the  administration  of  cer- 
tain drugs,  as  phosphorus,  quinin,  salicylic  acid,  arsenic,  bella- 
donna, etc. ;  or  it  may  occur  without  any  apparent  cause.  It 
occurs  chiefly  under  10  years  of  age. 

Pathology. — No  definite  pathology  is  known,  except  there  is 
an  endarteritis,  without  characteristic  changes  in  the  blood. 
Hemorrhages  occur  in  the  internal  organs,  chiefly  the  supra- 
renal capsules. 

Symptoms. — In  the  ordinary  form,  purpura  simplex,  after 
a  day  or  so  of  indisposition,  headache,  anorexia,  perhaps  some 
indigestion,  a  number  of  petechial  spots  appear  upon  the  skin, 
chiefly  at  first  upon  the  anterior  surface  of  the  lower  extremi- 
ties and  buttocks,  and  finally  generally  upon  the  whole  body. 
Later  there  may  be  larger  areas  of  extravasation,  large,  bruise- 
like spots.  As  the  hemorrhage  is  absorbed  it  leaves  a  bluish- 
black  discoloration.  Not  infrequently  some  fever  is  seen,  to 
100°  F.,  or  slightly  more.  Joint  pains  may  be  present  in  older 
children. 

Purpura  hemorrhagica  (also  called  morbus  maeulosus,  Werl- 
hoff 's  disease). 

In  this  form,  besides  the  skin  hemorrhages,  petechial  and 
ecchymotic,  there  are  hemorrhages  into  and  from  the  mucous 
membranes,  hematemesis  and  bloody  stools,  nosebleed  (the  most 
common)  and  exophthalmos,  caused  by  orbital  hemorrhage. 
The  skin  hemorrhages  are  more  numerous.  Joint  pains,  due  to 
hemorrhages  into  them,  are  common.  There  are  some  consti- 
tutional symptoms,  temperature  from  101°  F.  to  103°  F.,  with 
prostration,  dry  tongue  and  mouth,  sleeplessness,  the  patient  fall- 
ing into  the  typhoid  state,  with  coma  or  delerium. 

Blood  which  has  been  swallowed  should  be  differentiated  from 
true  melena. 

Where  the  case  progresses  rapidly  and  is  quickly  fatal  it  is 
referred  to  as  purpura  fulminans. 

Henoch's  Purpura. — In  this  form  there  are  three  groups  of 
symptoms  described;  sHw  presenting  petechial  and  ecchymotic 


DISEASES  OF   THE  BLOOD.  467 

hemorrhages,  besides  urticaria,  and  perhaps  edema;  swelling 
and  pain  in  one  or  more  joints ;  and  the  visceral  symptoms,  con- 
sisting of  colic,  diarrhea  and  vomiting,  and  occasionally  the 
passage  of  blood  both  ways.  In  addition  there  may  be  hemor 
turia,  as  well  as  an  albuminuria. 

The  tendency  in  this  form  is  to  be  apparently  entirely  relieved, 
with  recurrences  over  a  period  lasting  perhaps  several  years. 

Purpura  rheumatica  (Schonlein)  is  the  occurrence  of  hem- 
orrhages in  the  skin  in  an  attack  of  rheumatism.  There  are  en- 
larged and  painful  joints,  with  frequent  endocardial  involve- 
ment, temperature,  albuminuria,  erythema  nodosum,  etc. 

Prognosis  depends  upon  the  form  of  purpura.  In  the  simple 
form  it  is  good,  with  tendency  to  relapses;  in  the  hemorrhagic 
form,  where  the  bleeding  is  not  profuse,  the  child  may  recover. 
In  the  fulminans  type  it  is  rapidly  fatal;  in  Henoch's  purpura 
recoveries  are  rare,  where  it  has  recurred  frequently. 

Treatment. — In  all  varieties  the  child  should  be  put  to  bed 
and  kept  there  until  all  symptoms  are  relieved.  An  antiscor- 
butic diet,  fruit  juices,  fresh  milk  and  vegetables  should  be 
given.  Ergot  has  been  tried  without  success.  If  the  hemor- 
rhage is  profuse,  subcutaneous  injection  of  gelatine  solution 
should  be  tried.  Direct  transfusion  of  blood  may  offer  some 
lielp.  Adrenalin,  five  minims  of  a  1 :1000  solution,  hypodermat- 
ically  can  also  be  used.  Iron  and  tonics  are  indicated  in  con- 
valescence.    Normal  horse  serum  may  be  used. 

HEMOPHILIA. 

Definition. — This  is  a  hereditary  disease  in  which  there  is 
a  tendency  to  severe  bleeding  from  any  surface,  from  a  very 
slight  abrasion,  or  into  the  tissues.  One  so  affected  is  called  a 
''bleeder." 

Etiology. — The  hereditary  tendency  in  typical  cases  is  quite 
marked,  and  may  be  traced  through  several  generations,  with 
one  or  more  of  each  family  similarly  affected.  Males  are  oftener 
affected  than  females,  but  the  transmission  of  the  tendency  is 
more  often  through  the  female  side  of  the  family,  though  she 
may  herself  escape  it.  Even  though  herself  healthy,  and  mar- 
ried to  a  healthy  man,  their  male  offspring  are  liable  to 
develop  it. 


468  THE  DISEASES  OP   CHILDREN. 

Race  may  play  a  part.  It  is  frequent  in  the  Jews.  It  may 
develop  in  early  infancy  or  be  delayed  until  after  the  eruption 
of  the  deciduous  teeth. 

Pathology. — This  is  unknown.  There  may  be  an  endarteritis 
or  a  thinning  of  the  vessel  walls.  The  chief  change  in  the  blood 
is  the  lack  of  coagulability. 

Symptoms. — The  condition  may  go  unrecognized  until  a 
bleeding  occurs  from  an  apparently  trivial  cut  or  abrasion, 
which  assumes  an  alarming  proportion  quickly.  If  an  abrasion  it 
may  be  an  oozing,  which  pressure  or  other  hemostatic  measures 
ordinarily  used  does  not  stop.  The  bleeding  may  occur  from  the 
mucous  membranes,  especially  the  nose,  following  trauma,  into 
the  skin  or  joints.  A  mere  scratch,  the  pulling  of  a  tooth,  the 
cutting  of  a  tooth  in  an  infant,  may  cause  severe  and  dangerous 
bleeding. 

Diagnosis. — This  can  be  made  from  the  amount  of  hemor- 
rhage which  follows  a  trivial  abrasion,  cut  or  trauma,  and  the 
distinct  hereditary  history. 

Prognosis. — These  children,  if  the  case  is  a  decided  one, 
rarely  live  to  puberty;  should  they  pass  this  period  the  chance 
of  death  being  caused  from  hemophilia  grows  less  and  less. 
There  is  no  great  tendency  to  increased  bleeding  in  females  at 
menstruation  or  postpartum. 

Treatment. — Prophylaxis  is  the  main  consideration.  Pre- 
vention of  cuts  and  trauma,  but  if  trauma  should  occur  the  hem- 
orrhage should  be  stopped  as  quickly  as  possible.  Styptics  are 
not  of  very  great  benefit  but  should  be  tried,  perchloride  of 
iron,  tannic  acid  or  adrenalin  may  be  used.  Rest  in  bed  should 
be  insisted  upon.  Operations  should  not  be  performed,  espe- 
cially removal  of  the  tonsils  and  adenoids.  Adrenalin  (1:1000, 
5  or  10  min.)  ergot,  liquor  ferri  chloridi  (20  niin.)  can  be  used 
internally.     Fuller  recommends  the  use  of  thyroid  extract. 

Normal  horse  serum  should  be  used  before  the  case  is  hopeless. 


CHAPTER  XIX. 

DISEASES  OF  THE  LYMPHATIC  GLANDS. 

The  lymph  nodes  are  very  prone  to  develop  hyperplastic  proc- 
esses during  infancy.  Any  group  of  glands  may  enlarge,  or 
there  may  be  a  general  enlargement  of  all  of  them. 

THE  THYMUS  GLAND. 

But  little  definite  is  known  of  the  function  of  this  ductless 
gland.  It  is  quite  regularly  enlarged  in  the  infant,  and  to  it 
have  been  ascribed  sudden  deaths  occurring  without  apparent 
cause  in  cases  in  which  it  was  found  to  be  enlarged. 

It  is  found  to  extend  from  slightly  above  the  sternal  notch 
to  the  third  or  fourth  costal  cartilage,  and  may  be  2  inches  or 
more  in  width,  and  it  may  weigh  from  14  to  2  ounces. 

The  thymus  is  best  outlined  by  percussion,  showing  as  a  tri- 
angular area  of  dulness,  irregular  in  outline,  its  base  at  the 
sternoclavicular  margin  and  the  apex  at  the  second  rib. 
The  sides  of  the  triangle  extend  slightly  beyond  the  margin  of 
the  sternum,  a  little  more  so  on  the  left  than  the  right.  The 
thymus  and  precordial  area  of  dulness  may  coalesce. 

In  children  with  an  enlarged  thymus,  a  condition  of  status 
li/mphaticiis  exists.  The  subjects  are  pale,  anemic  and  pasty 
in  appearance,  and  in  older  children,  especially  girls,  the  symp- 
toms are  those  of  a  chlorosis.  There  is  usually  a  general  en- 
largement of  the  superficial  lymph  nodes.  They  have  but  little 
resistance  to  infectious  diseases,  and  are  frequently  affected 
with  tonsillitis  and  bronchitis.  Sudden  death  in  these  children, 
is  not  rare,  especially  as  a  result  of  a  general  anesthetic,  more 
especially  chloroform.  The  death  may  occur  after  the  first  few 
inhalations,  during  the  operation  or  after  the  removal  of  the 
cone.     This  should  always  be  borne  in  mind  before  an  anes- 

469 


470  THE  DISEASES  OF   CHILDREN. 

thetic  is  given,  when  a  diagnosis  of  this  condition  of  status 
lymphaticus  is  made. 

In  eases  of  sudden  death  due  to  enlarged  thymus,  there  is 
nothing  else  found  at  autopsy  which  can  be  looked  upon  as  a 
cause.  The  only  symptom  which  may  be  present  is  a  sudden 
lividity,  or  cyanosis,  followed  by  death.  Direct  pressure  of  the 
gland  upon  the  trachea  or  the  recurrent  laryngeal  or  vagus 
nerve  may  be  the  cause  of  the  death. 

No  treatment  is  of  avail. 

ACUTE  ADENITIS. 

Definitioii. — An  acute  inflammation  and  enlargement  of  the 
lymph  nodes,  local  or  general. 

Etiology. — This  condition  is  secondary  to  an  inflammation 
of  adjacent  structures,  skin  or  mucous  membrane.  The  extent 
of  the  inflammation  and  number  of  glands  involved  depends  on 
the  extent  of  area  of  skin  or  membrane  involved  in  the  inflam- 
mation. The  bronchial  lymph  nodes  may  be  primarily  involved 
from  tubercular  invasion,  by  direct  absorption  of  the  bacilli 
from  the  bronchial  mucous  membrane  or  the  intestine. 

Mesenteric  enlargement  occurs  from  absorption  of  tubercle 
bacilli  and  from  acute  inflammatory  conditions  of  the  intestinal 
tract. 

Inflammations  of  the  mucous  membrane  of  the  nose  and 
throat,  mouth,  the  pharynx  and  larynx  cause  an  inflammation 
of  the  deep  cervical  glands,  and  an  inflammation  of  the  scalp, 
face  and  ear,  cause  an  enlargement  of  the  superficial  glands  of 
the  neck.  Vaccination  upon  the  leg  may  cause  a  severe  inflam- 
mation of  the  inguinal  glands. 

Pathology. — There  is  an  acute  congestion  of  the  gland  with 
hyperplasia  of  the  lymphoid  structure.  If  there  is  direct  in- 
vasion of  the  pus-producing  organisms,  a  softening  and  breaking 
down  of  the  gland  usually  occurs. 

Symptoms. — ^When  secondary  to  other  conditions,  there  is  a 
rise  in  temperature,  with  swelling  of  the  glands.  If  it  is  severe, 
redness  of  the  skin  over  it  develops,  and  it  becomes  quite  tender 
and  painful.  An  adjacent  cellulitis  may  develop.  In  the  acute 
cases  there  is  temperature,  irritability  and  restlessness. 


DISEASES   OF   THE   LYMPHATIC   GLANDS.  471 

Without  suppuration  the  gland  may  remain  firm  and  hard  as 
long  as  the  inflammation  of  the  adjacent  structures  continues, 
and  upon  its  relief  the  gland  subsides. 

A  relapse  of  the  cause  will  again  cause  enlargement  of  the 
glands. 

Prognosis. — Except  in  tubercular  glandular  enlargement  re- 
covery follows,  but  not  always  without  suppuration  and  destruc- 
tion of  the  gland.  In  marasmic  and  cachectic  children  the  con- 
dition is  apt  to  develop  into  the  chronic  form. 

Treatment. — The  cause  must  be  sought  and  removed,  disease 
of  the  scalp  and  the  mucous  membrane  treated. 

Locally  much  good  can  be  accomplished  in  the  acute  cases, 
without  apparent  pus  formation,  by  the  application  of  50  per 
cent  grain  alcohol  poultices  on  absorbent  gauze,  protected  by 
rubber  tissue,  or  the  application  of  pure  ichthyol.  Mud  poul- 
tices do  no  good,  save  to  hold  the  part  fixed,  thus  saving  pain. 

When  much  redness  of  the  skin  takes  place  and  an  area  of 
softening,  indicating  pus  formation,  a  free  incision  should  be 
made  and  the  gland  drained. 

Where  they  remain  enlarged  after  subsidence  of  the  con- 
tiguous inflammation,  iodine  in  some  form  should  be  adminis- 
tered, the  iodide  of  iron  or  hydriodic  acid  being  beneficial. 

CHRONIC  ADENITIS. 

This  condition,  in  which  there  is  a  chronic  inflammation  and 
hyperplasia  of  the  lymph  nodes,  usually  follows  an  acute  attack 
of  inflammation.  It  may  occur  coincidently  with  a  long-stand- 
ing and  chronic  inflammation  of  the  skin,  as  an  eczema  of  the 
scalp,  or  of  the  mucous  membranes  of  the  nasopharynx  and 
pharynx. 

Symptoms. — The  chief  symptoms  are  the  presence  of  en- 
larged glands,  superficially  situated  about  the  body,  as  at  the 
back  of  the  neck,  in  the  axilla  and  in  the  groin.  These  glands  or 
groups  of  glands  are  hard,  not  tender,  and  show  no  tendency  to 
break  down  or  suppurate.  The  tendency  is  for  them  to  remain 
stationary  for  some  time,  perhaps  months,  and  then  to  gradu- 
ally become  smaller.  The  process  is  simply  one  of  a  hyperplasia 
of  the  connective  tissue  without  inflammation.     There  is  no  fever 


472  THE   DISEASES   OP    CHILDREN. 

or  inconvenience  suffered  by  the  child.  It  occurs  most  often 
under  10  years  of  age.  In  enlargement  of  the  bronchial  glands 
of  sufficient  size  to  cause  pressure  a  cough  is  present. 

Diagnosis. — If  the  glands  assume  some  size  the  condition 
becomes  suspicious  of  a  general  blood  trouble,  as  Hodgkin's  dis- 
ease, or  perhaps  tuberculosis  may  be  suspected. 

Treatment. — Remove  or  alleviate  the  cause.  If  a  skin  lesion 
treat  it  properly;  if  there  are  chronically  enlarged  tonsils  or 
adenoids  they  should  be  removed;  the  nose  should  also  receive 
attention.  Potassium  iodide  is  of  great  service  in  the  form  of 
syrup  of  the  iodide  of  iron  or  hydriodic  acid.  Cod  liver  oil, 
not  the  extracts  of  the  oil,  given  in  the  cool  months,  is  of  great 
benefit.  Good  and  nourishing  food  must  be  given,  change  of 
surroundings,  perhaps  of  climate,  may  be  indicated. 

If  the  underlying  bacterial  cause  can  be  ascertained  the  vac- 
cines might  be  used  with  benefit. 

ADDISON'S  DISEASE. 

This  is  quite  a  rare  disease  in  children.  Comby  has  selected 
21  cases  in  literature;  practically  never  seen  under  10  years 
of  age. 

It  is  characterized  by  the  same  train  of  symptoms  as  seen  in 
adults,  viz.,  bronzing  of  the  skin,  which  is  due  to  a  deposit  of 
pigment  in  the  m.alpighian  layer,  progressive  weakness  of  gen- 
eral muscular  system  and  pulse,  and  gastrointestinal  symptoms, 
as  vomiting  and  diarrhea.  The  bronzing  is  chiefly  of  the  ex- 
posed parts  of  the  body,  though  the  rest  of  the  body  may  be 
as  deeply  pigmented. 

Pathology. — The  chief  change  is  a  tuberculosis  of  the  adrenal 
glands,  with  later  tuberculosis  in  other  organs,  lungs,  spleen, 
liver  and  glands. 

Diagnosis. — Pigmentation  of  skin  from  arsenic  and  exposure 
must  be  borne  in  mind;  neither  are  attended  with  the  general 
symptoms  referred  to. 

Prognosis. — This  is  always  grave. 

Treatment. — Tonic  and  supportive  treatment  is  indicated. 
From  the  location  of  the  chief  lesion,  the  suprarenals,  adrenalin 
may  be  tried,  given  in  2  or  3  drops  of  1 :1000  solution.  Symp- 
tomatic treatment  must  be  carried  out. 


DISEASES   OF   THE    LYMPHATIC   GLANDS.  473 

CRETINISM  (MYXEDEMA). 

Definition. — This  is  a  condition  which  evidences  itself  by  a 
remarkable  backwardness  of  the  child  in  its  growth,  of  body  and 
mind,  an  abundance  of  deposit  of  fat  or  mucin  out  of  propor- 
tion to  its  bodily  growth;  in  other  words  a  persistence  of  in- 
fantilism. 

Etiology. — Nothing  very  definite  is  known  of  the  cause.  It 
has  long  been  known  to  be  prevalent  in  certain  mountainous 
and  limestone  districts  of  Switzerland.  This  is  looked  on  as 
the  endemic  form.  Sporadic  cases  develop  in  any  country,  and 
a  number  have  been  reported  in  the  United  States. 

The  thyroid  gland  is  at  fault,  an  insufficient  secretion  being 
the  cause.  It  may  follow  the  exanthemata,  though  just  what 
the  connection  between  them  is  we  do  not  know. 

Pathology. — The  thyroid  gland  is  usually  atrophied,  or  there 
may  rarely  be  an  enlargement,  a  goitre.     Ossification  is  delayed. 

Symptoms. — There  is  no  regularity  in  regard  to  the  onset. 
It  is  usually  insidious,  coming  on  as  a  rule  after  the  second  year, 
but  may  appear  soon  after  birth.  These  cases  have  the  appear- 
ance of  a  dwarf,  the  extremities  are  short,  the  body  apparently 
too  large.  The  face  is  expressionless  and  idiotic  when  the  tongue 
protrudes  from  the  mouth.  The  mouth  is  constantly  open, 
and  there  is  constantly  a  flow  of  saliva.  The  eyes  are  expres- 
sionless and  the  eyelids  baggy.  The  teeth  are  cut  late,  are  irreg- 
ular in  shape  and  decay  quickly.  There  is  an  anterior  curvature 
of  the  spine.  The  temperature  is  usually  below  normal,  the 
skin  baggy,  harsh,  cold  and  quite  anemic  and  pale.  The  face  is 
expressionless  and  the  child  apparently  has  no  intellection  what- 
ever. The  broadening  of  the  base  of  the  nose  is  characteristic. 
The  fontanelles,  especially  the  anterior,  are  apt  to  be  open. 
There  is  a  "pot  belly,"  which  is  quite  marked.  They  usually 
show  no  sign  of  talking,  and  sounds  made  are  harsh  and  un- 
natural. They  may  be  able  to  stand,  and  if  urged,  to  take  a  few 
steps,  but  usually  show  no  inclination  to  walk.  Other  cretins 
may  be  in  the  family,  usually,  however,  other  children  are  nor- 
mal. 

Diagnosis. — A  mental  picture  of  this  condition  should  make 
diagnosis  easy.     From  Mongolian  idiocy  the  diagnosis  may  not 


474  THE   DISEASES   OF    CHILDREN. 

be  so  easily  made.  In  the  latter  there  is  the  Mongolian  facies, 
they  are  more  intelligent  and  not  so  deformed,  the  skin  is  not 
thickened,  and  the  bridge  of  the  nose  not  so  wide.  In  this  form 
the  characteristic  curving  inward  of  the  tip  of  the  little  finger 
is  generally  seen.  Other  conditions  may  be  confounded,  as 
infantilism,  in  which  the  infantile  expression  and  size  are  main- 
tained, with  an  atrophy  of  the  genitalia.  The  skin  is  soft  but 
dry,  and  appendages  unhealthy;  the  mind  is  infantile  also. 

Infantilism  of  the  Lorain  type  is  described  as  a  condition  in 
which  there  is  an  imperfect  development  of  the  arterial  sys- 
tem, causing  insufficient  nourishment.  There  is  a  premature 
ossification  and  stunted  growth.  A  skiagraph  of  the  hand  shows 
ossification  complete,  while  in  myxedema  there  is  a  deficiency 
in  the  appearance  of  the  nuclei  of  the  carpal  bones,  and  a  failure 
of  phalanges  and  metacarpals  to  unite.  Thyroid  treatment  in 
this  class  of  cases  is  unavailing. 

Prognosis. — These  cases,  if  unrecognized  and  untreated,  may 
live  considerably  beyond  puberty,  but  maintain  the  idiotic  look 
and  mind,  and  dwarfed  body.  If  the  cases  are  recognized  and 
treatment  begun  early,  the  results  are  quite  brilliant.  Good 
results  have  been  reported  when  treatment  has  begun  after 
puberty. 

Treatment. — As  stated,  the  treatment  of  cretinism  is  brilliant 
in  its  results.  Thyroid  extract  given  internally  quickly  restores 
the  child  to  normal.  Dessicated  thyroid  extract  can  be  given 
in  tablet  form,  3^^  to  3  grains  at  a  dose  at  first,  increased  to 
5  grains  at  a  dose,  three  times  a  day.  To  infants,  i/i  grain  or 
14  gr.  should  be  given  at  first,  gradually  increasing  to  1  or  2 
grains.  The  thyroid  should  be  given  over  a  long  period  of  time, 
at  least  four  or  five  months,  the  dose  then  being  given  less  often, 
with  a  few  days'  rest  between.  At  first  there  may  be  a  slight 
depressing  influence  from  its  use. 

The  first  improvement  occurs  in  a  week  or  so,  and  is  in  the 
facial  expression.  The  tongue  no  longer  appears  too  large  for 
the  mouth,  the  dribbling  of  saliva  ceases,  the  skin  loses  its 
myxedematous  feel  and  appearance,  the  hair  looks  more  natural, 
delayed  teething  takes  place,  the  mental  condition  seems  to 
quickly  assume  its  proper  proportions. 


DISEASES   OF   THE   LYMPHATIC   GLANDS.  475 

After  the  discontinuance  of  the  regular  dose  of  thyroid  for 
several  weeks,  it  is  again  given  once  or  twice  a  week  for  several 
months,  and  for  a  long  time  the  child  should  be  kept  under 
observation  and  the  thyroid  given  if  indications  of  mental  dul- 
ness  or  sluggishness  again  appear.  It  may  be  necessary  to  con- 
tinue the  treatment  by  thyroid  for  life. 


CHAPTER  XX. 

DISEASES  OF  THE  GENITOURINARY  SYSTEM. 

THE  URINE. 

The  urine  of  a  healthy  infant  should  be  nearly  colorless, 
should  not  stain  the  napkin,  and  of  a  low  specific  gravity,  from 
1004  to  1010.  In  the  new-born  the  amount  passed  is  much 
less  than  in  older  children,  during  the  first  24  hours,  probably 
not  averaging  more  than  an  ounce.  During  this  time  there  is 
apt  to  be  a  relatively  large  amount  of  the  salts  of  urea,  which 
appears  as  a  very  fine  sand,  and  the  urine  is  much  thicker  than 
normal.  The  uric  acid  may  collect  as  infarcts  in  the  kidney  and 
cause  a  suppression  of  urine  until  dislodged  and  washed  out. 
The  failure  to  pass  urine  during  the  first  24  hours  is  an  indica- 
tion for  the  administration  of  water,  both  by  the  mouth  and 
the  bowel,  to  thoroughly  flush  the  kidneys. 

Uric  acid  remains  relatively  large  in  amount  in  proportion 
to  the  other  urinary  constituents  during  childhood. 

It  is  often  difficult  to  obtain  a  sample  of  urine  from  an  infant 
for  examination,  and  next  to  impossible  to  obtain  a  24-hour 
specimen.  In  male  infants,  by  attaching  a  rubber  condom  to 
the  genital  organs,  including  scrotum  and  penis  in  the  neck  of 
the  rubber,  and  fastening  by  tapes  around  the  waist,  enough 
urine  for  a  chemical  and  microscopic  examination  can  easily 
be  obtained.  In  girl  babies  this  is  often  much  more  difficult. 
The  appliance  suggested  by  Chapin  is  a  most  useful  one,  and 
can  be  applied  to  the  vulva  and  retained  by  tapes  tied  to  the 
thighs  or  waist  and  worn  without  discomfort  until  the  sample 
needed  is  obtained.  The  end  of  the  urinal  is  put  in  a  bottle, 
or  a  rubber  tube  attached,  and  its  free  end  placed  in  a  bottle. 

Placing  the  child  upon  a  rubber  sheet  without  napkin  or  pro- 
tective dressing,  or  placing  a  sterile  sponge  or  piece  of  gauze 

476 


DISEASES   OP   THE   GENITOURINARY   SYSTEM.  477 

over  the  vulva  or  the  penis,  which  as  soon  as  wet  is  squeezed 
into  a  test  tube,  later  filtered,  may  be  successful  if  persisted  in 
long  enough. 

The  difficulty  attending  the  obtaining  of  a  sample  of  urine 
has  unquestionably  been  the  cause  of  neglect  in  the  examina- 
tion of  the  urine  of  infants  in  the  past,  but  even  if  catheteriza- 
tion must  be  resorted  to  in  order  to  obtain  a  specimen  for  exam- 
ination, it  should  be  done.  Many  obscure  cases  can  be  cleared 
up  if  the  urine  is  examined,  and  too  great  emphasis  cannot 
be  laid  upon  it. 

During  the  third  month  it  is  estimated  200  cc.  of  urine  are 
passed  in  24  hours  with  a  specific  gravity  from  1004  to  1010, 
and  from  1  to  2  grams  of  urea;  during  the  sixth  month,  250 
cc.  of  urine,  in  24  hours ;  specific  gravity,  1006  to  1012 ;  during 
the  twelfth  month,  400  cc.  in  24  hours,  with  11  grams  or  urea ; 
from  two  to  five  years,  500  to  800  cc.  in  24  hours ;  .five  to  eight 
years,  600  to  1200  cc.  in  24  hours;  eight  to  fifteen  years,  1000 
to  1500  cc.  in  24  hours.  The  urine  gradually  increases  in 
amount  to  1000  cc.  in  the  tenth  year,  with  a  specific  gravity 
of  1015,  and  20  grams  of  urea. 

ALBUMINURIA. 

Normal  urine  contains  nucleoalbumin,  but  not  serumalbumin, 
and  when  serumalbumin  is  present  it  should  be  considered 
abnormal,  and  the  indication  of  pathologic  conditions.  Serum- 
albumin is  sometimes,  but  not  with  any  regularity,  found  in 
the  urine  of  infants  during  the  first  week  after  birth,  but  its 
persistence  is  indicative  of  abnormalities,  such  as  nephritis,  the 
acute  and  chronic  parenchymatous  forms,  pus  in  any  organ  or 
cavity,  etc.  Albumin  is  quite  regularly  present  during  the 
acute  diseases  of  childhood. 

Croftan  ^  describes  an  intermittent  albuminuria  and  a  cyclic 
albuminuria.  He  gives  as  causes  of  the  first,  nervous  influences, 
exposure  to  cold,  diet  and  overexertion,  and  describes  a  dyspeptic 
albuminuria,  which  is  present  in  intestinal  disorders  and  dila- 
tation of  the  stomach.  This  form  of  albuminuria  if  continued 
for  a  long  period  leads  to  true  nephritis. 


1  Croftan :   Clinical   Urolog^y. 


478  THE   DISEASES  OF    CHILDREN. 

The  urine  of  the  infant  is  but  faintly  acid,  often  alkaline 
in  reaction. 

CYCLIC,  or  FUNCTIONAL  ALBUMINURIA. 

This  condition  is  not  infrequent  in  older  children,  especially 
about  the  age  of  puberty.  As  the  name  implies,  albumin  may 
be  found  in  the  urine  during  certain  hours  in  the  day,  and  at 
other  times  it  is  absent. 

Etiology. — It  is  seen  most  often  in  boys.  It  has  been 
thought  to  be  due  to  severe  and  fatiguing  exercise;  cold  and 
prolonged  bathing ;  exposure  to  cold ;  continued  indigestion ; 
lithemia ;  but  Crof tan  believes  only  two  factors  are  to  be  con- 
sidered in  its  etiology,  viz.,  changes  in  the  position  of  the  body 
and  muscular  fatigue.  The  theory  of  the  postural  cause  is  that 
the  albuminuria  "is  due  to  a  certain  reactive  insufficiency  of 
the  circulatory  apparatus,"  that  it  is  a  "manifestation  of  a 
vasomotor  fatigue. ' ' 

Pathology. — This  form  of  trouble  has  no  pathology,  as  there 
are  no  pathological  changes.  When  an  albuminuria  is  due  to  a 
change  in  the  kidneys,  the  condition  is  no  longer  a  functional 
trouble. 

Symptoms. — Usually  the  albuminuria  is  discovered  accident- 
ally, as  the  child  may  not  present  any  symptoms.  The  chief 
and  only  symptom  perhaps  may  be  an  indigestion,  and  if  per- 
sistent long,  an  anemia. 

The  urine  does  not  show  albumin  continuously  as  indicated 
by  the  name  given  the  trouble.  No  albumin  may  be  present  on 
arising,  but  by  noon  it  is  shown  to  some  extent,  and  persists 
until  night,  when  the  amount  gradually  decreases,  a  prolonged 
stay  and  rest  in  bed  may  clear  the  urine  entirely.  An  increase 
in  the  urinary  salts  may  be  seen,  uric  acid,  urates  and  oxalates. 

Dia.giiosis. — In  every  case  of  albuminuria  the  symptoms  and 
urinary  findings  should  be  carefully  weighed  before  a  diagnosis 
is  made.  Frequent  and  careful  chemical  and  microscopic  exam- 
ination of  the  urine  should  be  made  to  exclude  a  nephritis.  The 
presence  of  casts  in  a  centrifugalized  specimen  of  urine  is  sufR- 
cient  to  exclude  functional  albuminuria. 

Prognosis. — Where  the  diagnosis  can  be  made  positively  the 
prognosis  is  favorable. 


DISEASES   OP   THE   GENITOURINARY   SYSTEM.  479 

A  persistent  albuminuria  should  be  regarded  with  suspicion, 
as  indicative  of  organic  changes  in  the  kidney. 

Treatment. — Rest  in  bed  while  the  quantity  of  albumin  is 
large,  careful  diet,  limiting  the  amount  of  nitrogenous  foods; 
regular  and  graduated  exercises,  never  to  the  point  of  fatigue, 
and  not  violent  at  any  time.  Occasional  blood  pressure  tests 
should  be  made. 

Occasional  doses  of  calomel  are  of  great  benefit,  with  a  mild 
saline  following;  and  as  suggested  by  Croftan  ''on  the  basis 
of  the  vasomotor  fatigue  theory,  cardiac  tonics  are  indicated, 
and  good  results  have  been  obtained  by  this  therapy." 

Change  in  climate  may  be  necessary,  to  a  warmer,  more 
equable  one. 

PYELITIS. 

Definition. — An  inflammation  of  the  lining  membrane  of  the 
pelvis  of  the  kidney.  When  the  inflammation  extends  to  the 
tubules  of  the  kidney  it  is  a  pyelonephritis ;  when  an  accumula- 
tion of  pus  in  the  kidney  takes  place,  a  pyonephrosis. 

Primary  and  secondary  pyelitis  have  been  described,  but  it 
is  difficult  to  draw  the  line  between  the  two. 

Etiology. — The  presence  of  a  calculus  in  the  pelvis  of  the 
kidney  may  act  as  an  exciting  cause.  It  occurs  more  frequently 
in  female  than  in  male  infants,  and  is  probably  due  to  an  exten- 
sion of  bacilli  from  the  vulva  and  vagina  to  the  pelvis  of  the 
kidney  without  a  coincident  urethritis  or  cystitis.  The  chief 
infecting  organism  is  the  colon  bacillus,  which  may  gain  en- 
trance direct  from  the  intestinal  tract.  A  diarrhea  may  precede 
the  acute  symptoms  of  the  pyelitis.  It  occurs  at  any  age,  but 
in  my  experience  most  often  in  female  infants  between  6  and 
18  months  of  age. 

It  may  complicate  the  exanthemata,  pneumonia  or  diphtheria 
or  a  general  pyemic  state. 

Pathology. — The  pathological  changes  are  those  of  acute  in- 
flammation of  a  mucous  membrane,  congestion,  swelling  with 
possibly  punctate  hemorrhage.  Pus  is  formed  and  is  washed  out 
with  the  urine.  If  the  accumulation  of  pus  is  greater  than  is 
thrown  off  in  this  way,  it  distends  the  pelvis  and  calices  and 
forms  a  pyelonephrosis. 


480  THE  DISEASES  OP   CHILDREN. 

Symptoms. — The  onset  is  usually  sudden  and  the  symptoms 
obscure.  The  chief  symptom  is  a  persistent  and  irregular  tem- 
perature, usually  to  105°  F.,  ushered  in  often  with  a  chill  or 
evidences  of  chilliness,  manifested  by  blueness  of  the  skin,  cold 
hands  and  feet  and  feeble  circulation.  The  temperature  may 
show  a  decided  remission  or  remain  persistently  high  with  but 
slight  remissions,  often  with  sweats. 

There  may  be  a  preceding  gastrointestinal  disturbance  or 
vomiting  without  any  bowel  disturbance. 

No  symptoms  are  present  as  a  rule  referable  to  the  kidneys, 
no  tenderness  or  pain  in  the  loin  or  abdomen,  though  occasional 
cases  are  seen  evidencing  considerable  pain  in  the  back.  Unless 
the  condition  is  recognized  by  a  careful  examination  of  the 
urine  the  case  may  continue  indefinitely,  showing  a  continuous 
temperature,  anorexia,  emaciation,  restlessness  and  profound 
anemia. 

The  urine  is  acid,  contains  albumin  and  on  microscopic  ex- 
amination, a  large  number  of  pus  cells  is  found.  The  urine  is 
diminished  in  amount,  is  apt  to  be  cloudy  from  the  pus  and 
kidney  epithelia  present.  The  epithelia  are  from  the  kidney 
pelvis  and  the  ureter.  If  the  condition  has  existed  long,  hyaline 
casts  may  be  found,  chiefly  of  large  size.  Many  actively  motile 
bacteria  are  present. 

In  the  so-called  secondary  form  of  pyelitis  in  which  a  calculus 
is  present,  there  is  pain  and  tenderness,  renal  colic  and  blood 
in  the  urine.  Bacteriological  examination  should  be  made  in 
long-standing  cases,  looking  especially  for  the  tubercle  bacillus. 

In  one  of  my  cases  the  microseopist  reported  the  presence  of 
foreign  bodies  resembling  the  ova  of  an  intestinal  parasite,  and 
it  was  puzzling  to  several  who  saw  it,  until  I  recalled  the  fact 
that  lycopodium  powder  was  used  on  the  buttocks,  and  the  sus- 
pected ovum  proved  to  be  the  seed  pod  of  the  lycopodium. 

Diagnosis. — This  is  not  always  easy,  but  wnll  be  made  much 
more  readily  and  often  if  sj'stematic  examinations  of  the  urine 
are  made.  Every  case  of  sudden  temperature,  in  which  diseases 
of.  the  gastrointestinal  tract  and  lungs  can  be  ruled  out,  a 
pyelitis  should  be  suspected,  and  a  careful  urinalysis  made. 
The  urinalysis  is  not  complete  without  a  microscopic  examina- 


DISEASES   OP   THE   GENITOURINARY   SYSTEM.  481 

tion.  Pus,  kidney  cells,  albumin,  a  highly  acid  urine  and 
bacteria  make  the  diagnosis  certain.  A  vulvovaginitis  must  be 
excluded,  but  in  this,  as  a  rule,  there  is  no  fever. 

Prognosis. — In  uncomplicated  pyelitis  the  prognosis  is  good. 
It  is  influenced  by  the  time  which  elapses  between  its  onset  and 
the  making  of  the  diagnosis.  Its  course  under  treatment  is 
usually  about  two  weeks,  and  recovery  is  the  rule. 

Treatment. — Hexamethylenamine  gives  almost  universally 
good  results.  It  is  administered  in  3  grain  doses  to  a  child  of 
one  year,  every  three  hours,  with  as  much  water  during  the  24 
hours  as  possible. 

If  there  is  a  complicating  enterocolitis  a  preliminary  dose  of 
calomel  and  castor  oil  should  be  given,  followed  by  a  colon 
injection  of  normal  salt  solution,  and  a  subsequent  daily  evacu- 
ation obtained.  To  neutralize  the  urinary  acidity.  Holt  recom- 
mends potassium  citrate,  2  or  3  grains,  well  diluted,  every  three 
hours.     Acetate  of  potassium  may  also  be  used. 

Unless  there  is  a  decided  abnormal  condition  of  the  bowels, 
no  change  is  made  in  the  diet;  milk,  however,  being  preferred 
to  any  other  article. 

In  cases  which  do  not  promptly  respond  to  urinary  anti- 
septics the  use  of  the  vaccines  offer  the  best  possible  results. 
A  careful  bacteriologic  examination  of  the  urine  is  made  and 
the  bacteria  identified.  If  of  the  pure  colon  strain,  the  stock 
colon  bacillus  vaccine  can  be  used  or  if  preferred,  and  a  com- 
petent laboratory  expert  is  available,  an  autogenous  vaccine  can 
be  made  and  administered. 

RENAL  CALCULUS. 

Synonym. — Stone  in  the  kidney. 

Etiology. — Stone  in  the  kidney  in  children  is  infrequent. 
They  have  their  origin  in  uric  acid,  though  they  may  contain 
oxalate  of  lime  also.  Large  calculi  are  comparatively  rare. 
Bacteria  and  cellular  detritus  in  an  inflammatory  condition  of 
the  pelvis  of  the  kidney  may  form  the  nidus  for  a  stone. 

Symptoms. — Small  calculi,  more  like  sand,  may  form  in  the 
pelvis  of  the  kidney  and  be  M'ashed  free  into  the  ureter  and 
bladder,  and  passed  from  the  bladder  with  the  urine.     These 


482  THE   DISEASES   OF    CHILDREN. 

frequently  cause  pain  in  their  passage  through  the  ureter,  evi- 
denced by  restlessness  and  crying,  a  diagnosis  of  the  condition 
not  being  made  until  the  sand  or  calculus  is  passed  from  the 
bladder  and  found  on  the  napkin  or  in  the  vessel.  In  the  male 
the  passage  of  the  sand  through  the  urethra  is  attended  with 
great  pain,  and  if  the  child  is  large  enough,  referred  to  the  end 
of  the  penis.  I  have  seen  one  stone  which  had  evidently  lodged 
for  some  time  in  the  glans  portion  of  the  urethra  and  grad- 
ually increased  in  size  there,  as  it  took  exactly  the  shape  of 
that  portion  of  the  urethra.  An  examination  was  made  to.  ascer- 
tain the  cause  of  the  painful  urination  and  this  stone  found, 
very  slightly  distending  the  meatus.  It  was  fished  out  with  a 
fine  hemostatic  forceps  and  complete  relief  afforded. 

If  the  stone  is  retained  in  the  pelvis  of  the  kidney  a  pj^elitis 
and  pyonephrosis  results.  Absorption  takes  place,  chills,  sweats, 
wasting,  prostration  and  great  pain,  caused  by  the  effort  to 
pass  it  on  through  the  ureter,  too  small  to  receive  it. 

If  renal  calculus  is  suspected  an  X-ray  photograph  should  be 
taken. 

Treatment. — Renal  colic  is  very  painful  and  usually  requires 
anodynes  for  its  relief.  Opium  in  some  form  is  necessary, 
paregoric  or  the  deodorized  tincture,  in  the  minimum  dose, 
repeated  if  need  be.  Relaxation  from  a  general  hot  bath  is  of 
service.  Hexamethylenamine  is  of  great  service  in  cases  with 
infection  from  pyelitis.  In  the  presence  of  very  great  pain, 
sepsis,  chills,  etc.,  the  condition  becomes  a  surgical  one,  and 
early  operation  for  drainage  should  be  performed. 

Liberal  water  drinking  in  this  condition  is  of  the  greatest 
benefit, 

PERINEPHRITIS. 

Definition. — This  is  an  inflammation  of  the  loose  connective 
tissue  surrounding  the  kidney,  with  or  without  the  formation 
of  pus. 

Etiology. — It  may  be  primary,  due  to  trauma,  exposure  and 
cold,  or  secondary,  following  the  acute  infectious  diseases,  pye- 
litis or  pyonephrosis,  vertebral  diseases,  or  renal  calculus. 

Pathology. — The    loose    connective    tissue    surrounding    the 


DISEASES   OF   THE  GENITOURINARY  SYSTEM.  483 

kidneys  undergoes  inflammatory  reaction  with  frequent  local- 
izing of  the  process  and  the  formation  of  an  abscess. 

Symptoms. — The  onset  is  sudden,  with  a  decided  chill  and 
pain  located  in  the  lumbar  region  of  the  affected  side.  The  pain 
is  reflected  along  the  psoas  muscle  to  the  inguinal  region,  groin 
or  the  thigh.  There  is  tenderness  over  the  loin  and  pain  is 
increased  by  walking  or  bending  forward,  and  a  decided  curva- 
ture of  the  spine  may  be  present. 

There  is  a  rise  of  temperature  with  septic  symptoms  and 
digestive  disturbances,  chiefly  vomiting,  in  the  acute  cases.  It 
may  begin  slowly  with  some  pain  and  tenderness,  increased  on 
movement.  If  the  abscess  forms  the  pus  will  travel  toward  the 
least  resistance,  may  open  on  the  skin,  or  follow  the  psoas  muscle 
and  open  on  the  thigh. 

Diagnosis. — This  must  be  made  from  pyelitis.  In  perine- 
phritis no  pus  cells  in  the  urine;  from  hip-joint  disease,  by 
limited  motion  of  leg,  and  atrophy  of  the  muscles  of  the  thigh, 
and  its  slow  onset;  from  Pott's  disease  of  the  spine,  with  psoas 
abscess. 

Treatment. — Absolute  rest  in  bed ;  light  diet ;  incision  of  the 
abscess  sac,  under  anesthesia,  if  it  is  thought  advisable.  An 
exploratory  puncture  can  be  utilized  at  any  time.  Application 
of  an  ice  bag  before  pus  has  localized  will  be  beneficial. 

ACUTE  PARENCHYMATOUS  NEPHRITIS. 

Synonyms. — -Acute  Bright 's  disease;  acute  exudative  nephri- 
tis; catarrhal  nephritis;  acute  desquamative  nephritis,  a^ute 
tubular  nephritis. 

Etiology. — This  form  of  nephritis  may  be  primary  or  sec- 
ondary, but  is  more  frequently  secondary.  Primary  nephritis 
is  rare.  Holt  has  collected  24  cases  from  his  practice  and  from 
literature.  I  have  seen  but  one  case  in  my  own  practice  with 
recovery.  Undue  exposure  is  the  most  frequently  reported 
cause  of  the  primary  form,  though  no  cause  may  be  found. 

The  secondary  form  is  generally  due  to  one  of  the  exanthemata 
or  infectious  diseases,  scarlet  fever  and  diphtheria  being  the 
most  frequent  causes.  In  various  epidemics  of  scarlet  fever 
the  number  of  cases  of  complicating  nephritis  vary  from  5  per 


484  THE  DISEASES   OF    CHILDREN. 

cent  to  70  per  cent.  It  may  occur  as  a  complication  in  septic 
conditions  from  any  cause,  notably  in  gastrointestinal  diseases, 
in  which  the  colon  bacilli  and  streptococci  are  present.  The 
pathological  condition  may  be  caused  by  the  organisms  them- 
selves or  their  toxins.  Among  other  causes  may  be  exposure 
to  cold,  and  the  continued  administration  of  certain  drugs,  hav- 
ing an  irritative  effect  upon  the  kidney  as  potassium  chlorate 
and  the  phenols. 

The  active  cause  of  the  inflammatory  condition  of  the  kidney 
in  the  infectious  diseases  is  the  irritating  effect  of  the  toxins 
on  the  parenchyma  of  the  kidneys. 

Pathology. — The  epithelia  are  degenerated,  the  kidney 
stroma  infiltrated  to  such  an  extent  that  the  kidney  is  enlarged 
and  softened.  The  capsule  is  not  adherent.  The  surface  of  the 
kidney  is  deeply  injected,  as  are  the  pyramids  on  section.  The 
tubules  are  dilated  and  contain  blood  cells  and  epithelia. 
Under  the  microscope  the  tubular  cells  show  degeneration  and 
cloudy  swelling. 

Symptoms. — Systemic. — The  onset  is  generally  abrupt.  In 
the  very  young  uremic  symptoms  may  be  manifest  early  by  the 
attack  being  ushered  in  by  a  convulsion;  vomiting  and  some- 
times diarrhea  are  present  early.  If  occurring  as  a  complica- 
tion of  the  exanthemata,  the  symptoms  begin  about  the  third 
week.  There  is  a  sharp  rise  of  temperature,  the  pulse  corres- 
pondingly rapid,  and  the  tension  quite  high.  Edema  is  present 
early,  in  the  face,  perhaps  only  the  eyelids,  the  legs  and  thighs. 
Ocular  symptoms  may  be  present  early,  spots  before  the  eyes  or 
even  blindness.  Headache  is  prominent  and  anemia  quickly 
appears. 

Focal. — The  nrine  is  very  scant,  cloudy  and  high  colored. 
The  specific  gravity  is  high,  and  albumin  is  present  in  consid- 
erable quantity,  usually  larger  if  the  amount  passed  is  small. 
The  quantity  of  urea  is  greatly  diminished. 

Microscopically,  all  varieties  of  casts,  large  and  small,  are 
found,  and  free-blood  cells  also.  If  the  urine  is  abundant,  the 
casts  may  not  be  as  numerous. 

In  the  secondary  form  the  symptoms  usually  present  late  in 
the  disease.     After  having  been  afebrile  the  temperature  rises 


DISEASES   OF   THE   GENITOURINARY   SYSTEM.  485 

again,  it  is  more  irregular,  and  not  quite  so  high,  the  child 
quickly  appears  sick  again,  after  an  apparently  satisfactory 
convalescence.  There  is  vomiting,  headache,  restlessness,  edema, 
and  much  the  same  urinary  symptoms  as  in  the  primary  form. 

The  duration  in  the  primary  form  is  from  three  or  four  days 
to  two  weeks,  and  in  the  secondary  form  a  slightly  longer  period. 

An  improvement  is  first  noticed  in  the  amount  of  urine  passed, 
lessened  amount  of  albumin,  fever,  renal  derivatives,  and  grad- 
ual improvement  in  all  the  symptoms. 

Prognosis. — The  younger  the  children  the  graver  the  prog- 
nosis. Either  form  of  nephritis  is  very  serious  in  the  young. 
Albumin  and  casts  may  both  persist  for  some  time  after  the 
acute  symptoms  subside. 

Complications. — Endocarditis,  pericarditis  with  effusion; 
meningitis ;  edema  of  the  glottis  or  pneumonia  may  occur. 

Treatment. — Prophylaxis. — During  the  infectious  diseases, 
prevention  from  exposure  to  cold;  a  carefully  regulated  diet  in 
which  milk  should  predominate;  regular  actions  from  bowels; 
plent}^  of  water  to  flush  the  kidneys;  keep  the  skin  active  by 
warm  baths.  Close  confinement  to  bed  in  these  infectious  cases 
may  often  prevent  kidney  involvement. 

Management. — Diagnosis  having  been  made,  active  treat- 
ment must  begin  with  promptness.  The  following  indications 
are  to  be  met:  (a)  Relieve  tidneys  of  the  extra  work  of  drain- 
ing the  serum  from  the  tissues,  as  well  as  from  excreting  the 
retained  products  of  tissue  metamorphosis;  (&)  restore  the 
kidney  to  its  normal  condition;  (c)  by  careful  and  intelligent 
medication  and  diet  prevent  further  damage  to  the  diseased 
organs;  (d)  rest  in  bed. 

Diet. — The  bulk  of  the  diet,  though  not  exclusively,  should 
be  milk,  whole,  or  in  the  form  of  buttermilk,  made  from  fresh 
milk.  To  this  should  be  added  well-cooked  cereals  and  toast 
with  butter.     Plenty  of  water  should  be  given  also. 

Medicinal. — Calomel  is  a  sheet  anchor  in  the  treatment  of 
acute  nephritis;  it  is  an  admirable  diuretic,  as  well  as  acting 
upon  the  upper  bowel.  It  should  be  repeated  at  intervals  of 
several  days.  The  initial  dose  should  not  be  less  than  2  grains. 
Later  salines,  citrate  of  magnesia,  rhubarb  and  soda,  cascara 


486  THE  DISEASES   OF   CHILDREN. 

sagrada,  or  compound  jalap  powder,  can  be  tried.  Nitroglyc- 
erine in  high  temperature,  vomiting  and  high-tension  pulse. 
Chloral  may  be  given  for  the  nervous  symptoms. 

Digitalis  is  of  great  service,  relieving  the  heart  and  assisting 
the  kidney  also.  Infusion  is  of  service;  fat-free  digitalis  yields 
good  results,  5  minims  to  child  of  one  year;  strychnia,  caffeine 
and  nitroglycerine  can  be  used  to  advantage  for  the  heart. 

Water,  by  the  mouth  if  possible,  enteroclysis  or  hypodermo- 
clysis,  is  of  great  assistance. 

If  edema  is  great,  diaphoretic  measures  can  be  used  to  advan- 
tage. Hot  wet -packs  and  the  hot-air  apparatus  bring  on  a  whole- 
some sweat,  with  relief  of  symptoms  promptly.  Pilocarpine 
should  be  used  with  great  caution. 

Dry  cups  over  the  loin  may  aid  in  relieving  renal  congestion. 
Blood-letting  has  been  advocated,  and  in  one  of  ray  cases  was 
used  with  decided  benefit.  From  2  to  5  ounces  can  be  removed 
without  deleterious  symptoms,  in  child  of  three  years. 

In  convalescence  iron  is  early  indicated  in  order  to  combat 
the  anemia,  which  is  usually  present.  At  this  time  acetate  or 
citrate  of  potassium  can  be  used  to  advantage. 

The  urine  must  be  constantly  watched  and  the  first  evidence 
of  increasing  trouble  instead  of  an  improvement  calls  for 
prompt  attention. 

CHRONIC  NEPHRITIS. 
Types. — Chranic   parenchymatous   nephritis.     Chronic   inter- 
s  titial  n  eph  ritis. 

Chronic  Parenchymatous  Nephritis. 

Etiology. — Comparatively  rare  at  any  age  of  childhood,  more 
common  late.  It  occurs  more  often  as  sequel  to  the  acute 
nephritis  than  as  a  primary  condition.  Prolonged  sepsis,  alco- 
holism, congenital  syphilis,  malaria,  chronic  gastrointestinal  in- 
flammations, etc.,  are  mentioned  as  causes. 

Pathology. — This  is  essentially  the  same  as  in  adults.  There 
is  an  enlargement  of  the  kidneys  due  to  new  connective  tissue, 
and  they  are  white  and  nodular  in  appearance. 

Symptoms. — Usually  this  form  originated  from  the  acute 
variety-  there  simply  being  an  amelioration  of  the  acute  symp- 


DISEASES   OF   THE   GENITOURINARY   SYSTEM.  487 

toms,  or  perhaps  a  disappearance  of  them  entirely  for  a  short 
while,  and  their  reappearance  in  this  form. 

The  symptoms  are  insidious,  until  the  dropsy  is  a  feature,  no 
special  attention  being  given  the  kidneys.  There  is  headache 
and  neuralgia,  lassitude  or  weariness,  loss  of  appetite,  vomiting, 
anemia.  The  dropsy  varies  in  amount,  but  usually  is  quite 
marked,  especially  of  face  and  extremities.  It  may  be  present 
for  a  time  and  disappear. 

The  urine  is  usually  diminished  in  quantity,  though  it  may 
be  normal  or  increased.  Specific  gravity  is  low,  and  albumin 
present  in  considerable  amount.  The  total  urea  output  is 
greatly  reduced.  All  the  renal  derivatives  may  be  present,  but 
granular  epithelia  are  more  numerous.  The  duration  is  very 
variable.  It  may  last  for  years.  It  is  essentially  a  chronic 
disease. 

Diagfnosis. — This  may  be  very  difficult.  It  will  certainly  be 
made  much  oftener  when  the  profession  as  a  whole  realizes  the 
importance  of  frequent  examination  of  the  urine  in  all  cases 
of  illness  in  children.  Any  progressive  anemia  with  digestive 
disturbance,  loss  of  weight  and  beginning  edema  should  make 
one  very  suspicious  of  the  kidneys,  and  call  for  an  examination 
of  tlie  urine. 

Prognosis.; — The  outlook  is  decidedly  bad.  The  course  of 
the  disease  is  chronic  with  occasional  acute  exacerbations.  It 
is  usually  one  of  these  acute  attacks  which  carries  the  child  oif. 
Some  cases  apparentlj^  recover  after  months  of  invalidism. 

Treatment. — General  Management.— Protection  from  ex- 
posure is  most  essential.  Warm,  part-wool  underclothing  should 
be  worn.  Careful  regulation  of  the  diet,  milk,  carbohydrates, 
cooked  fruits,  buttermilk  and  cereals  can  be  used.  Red  meats, 
eggs,  fish,  animal  broths,  should  be  avoided.  The  bowels  should 
be  carefully  watched.  Occasional  purgation  is  indicated  with 
irrigation  of  the  colon  and  warm  baths;  water  should  be  given 
freely. 

Eenal  decapsulation,  according  to  the  operation  suggested  by 
the  late  Dr.  G.  M.  Edebohls,  has  been  advocated,  several  suc- 
cessful cases  being  on  record.  It  is  an  operation  which  should 
be  done  with  great  caution. 


488  THE   DISEASES   OP    CHILDREN. 

Chronic  Interstitial  Nephritis. 

This  is  an  extremely  rare  condition  in  older  children  and 
practically  unknown  in  infants. 

Etiology. — Syphilis,  malaria,  tuberculosis,  have  been  named 
as  causes. 

Pathology. — These  kidneys  are  smaller  than  normal.  The 
capsule  is  adherent  and  there  is  a  proliferation  of  connective 
tissue.  If  the  connective  tissue  presses  upon  the  tubules  a 
condition  of  hydronephrosis  is  caused. 

Symptoms. — This  form  is  more  insidious  than  the  others. 
The  child  loses  in  weight  continuously  and  is  anemic.  Gastro- 
intestinal symptoms  are  prominent,  vomiting  is  frequent;  head- 
ache is  present,  and  eye  symptoms,  as  double  vision,  specks 
before  eyes,  or  complete  blindness,  may  occur.  There  is  usu- 
ally no  rise  in  temperature,  but  there  is  a  high-tension  pulse, 
and  the  left  heart  shows  dilatation. 

The  iiri7ie  is  increased  in  quantity  and  specific  gravity  is 
low.  Albumin  is  present  in  small  quantities  and  may  be  only 
occasionally  found  or  absent  entirely.  The  principal  casts  pres- 
ent are  the  hyaline,  though  the  other  varieties,  in  the  pres- 
ence of  an  acute  exacerbation  may  be  found. 

Prognosis.-:— This  is  always  bad.  The  tendency  is  to  a  fatal 
termination,  though  it  may  show  an  improvement  occasionally. 
The  duration  may  be  two  or  three  years. 

Treatment. — Not  a  great  deal  can  be  accomplished  save  the 
care  of  the  child,  protection  from  exposure  and  carefully  regu- 
late the  general  functions  of  the  body.  The  diet  should  be 
chiefly  milk,  but  occasional  meals  of  more  or  less  general  char- 
acter must  be  given,  if  anemia  is  a  prominent  symptom. 
Change  of  climate  is  often  of  great  benefit. 

TUMORS  OF  THE  KIDNEY. 

Varieties. — Benign  tumors  of  the  kidney  are  very  seldom 
seen.  The  vast  majority  of  this  form  of  growth  are  malignant, 
and  the  commonest  variety  is  a  sarcoma.  Any  portion  of  the 
kidney  may  be  primarily  involved,  with  secondary  involvement 


DISEASES   OP   THE   GENITOURINARY    SYSTEM.  489 

of  other  organs,  as  the  liver,  spleen  or  lungs.  A  variety  of 
growth  has  been  described  by  one  author  as  embryonal 
adenosarcoma. 

Etiology. — These  growths  are  essentially  peculiar  to  children, 
occurring  usually  between  six  months  and  four  and  a  half  or 
five  years  of  age.  It  is  rare  to  see  one  in  children  over  five 
years  of  age.  It  does  not  occur  oftener  in  one  sex  than  another. 
The  left  kidney  seems  to  be  more  often  affected.  The  direct 
cause  is  not  known. 

Symptoms. — The  condition  may  not  be  recognized  until  the 
growth  is  visible  to  the  eye.  Preceding  this  time  the  cachexia 
is  quite  marked,  there  is  apt  to  be  pain  and  occasionally  bloody 
urine. 

In  the  presence  of  the  latter  conditions  a  careful  palpation 
should  be  made  of  the  abdomen,  and  the  tumor  will  probably 
be  found.  At  first  its  growth  is  slow,  but  when  easily  palpable 
the  tumor  enlarges  with  greater  rapidity,  and  may  apparently 
fill  the  whole  abdominal  cavity  in  a  short  while.  The  feel  of 
the  tumor  is  usually  soft,  not  fluctuating,  but  a  distinct  give  to  it. 

Bloody  urine  is  a  very  common  symptom.  It  may  be 
demonstrable  only  by  the  microscope,  but  is  present  in  prac- 
tically all  cases.  Albumin  is  present,  principally  because  of  the 
blood.     Hyaline  casts  are  sometimes  found. 

The  first  symptom  to  call  attention  to  the  child  may  be  a 
distinct  cachexia,  a  something  in  the  countenance  and  the  skin 
which  usually  suggests  malignancy,  a  different  color  from  the 
anemia  of  tuberculosis.  The  child  loses  flesh  rapidly  and  the 
prominent  abdomen  soon  becomes  a  marked  symptom. 

Pain  more  or  less  severe  is  present  in  practically  all  cases. 
It  may  be  simply  a  dull  but  persistent  ache  or  a  severe  darting 
pain,  enough  to  make  the  child  cry  out. 

Diagnosis. — A  diagnostic  sign  usually  present  is  the  locali- 
zation of  the  colon,  shown  by  a  tympanitic  note  over  the  surround- 
ing dull  area. 

Kidney  tumors  are  the  most  frequent  of  abdominal  tumors 
in  children. 

Prognosis. — The  course  of  malignant  tumors  of  the  kidney  is 


490  THE   DISEASES   OP    CHILDREN". 

always  fatal  if  not  operated  upon.  Early  operation  yields 
good  results.  Unoperated  cases  die  within  six  months  or  two 
years.  The  earlier  the  diagnosis  and  operation  the  greater  the 
chance  of  recovery. 

Treatment. — This  is  essentially  surgical  as  no  other  treat- 
ment oifers  any  results.  Pain  usually  requires  anodynes; 
paregoric,  heroin,  codeine  or  morphia  may  be  given. 

Removal  of  the  kidney  and  ureter  for  some  distance  offers 
the  only  hope  of  recovery,  and  the  earlier  this  is  done  the  better 
the  outcome. 

HYDRONEPHROSIS. 

Definitioii. — This  is  either  congenital  or  acquired,  and  is 
either  a  cystic  degeneration  of  the  kidney  or  an  accumulation 
of  urine  in  the  pelvis  of  the  kidney  from  an  obstruction  of  the 
ureter. 

Etiology. — The  obstruction  of  the  ureter  at  any  point  in  the 
ureter,  may  be  caused  by  the  lodgement  of  a  stone  from  the 
kidney  or  contraction  of  the  vesical  orifice  of  the  ureter.  Ob- 
struction of  the  ureter  from  pressure  by  tumors  of  other  organs 
may  be  a  cause. 

Pathology. — A  tubule  of  the  kidney  may  become  blocked  and 
dilated,  forming  the  beginning  of  a  cyst.  If  obstruction  of  the 
ureter  is  present  the  pelvis  of  the  kidney  becomes  dilated  and 
the  cortical  portion  of  the  kidney  pressed  upon  until  it  is  a 
thin  shell.  The  kidney  is  larger  than  normal,  but  not  as  large 
as  a  malignant  growth.  A  double  hydronephrosis  may  be  pres- 
ent in  which  ease  the  obstruction  is  most  likely  low  down. 

Symptoms. — These  are  very  vague,  and  usually  no  diagnosis 
is  made  until  the  tumor  is  felt.  It  occurs  later  than  the  malig- 
nant growths  as  a  rule.  The  presence  of  the  urinary  findings 
of  nephritis  may  obscure  the  true  diagnosis. 

Prognosis. — Without  surgical  intervention  the  prognosis  is 
grave,  and  in  the  double  variety  the  end  comes  quickly. 

Treatment. — This  is  entirely  surgical,  and  when  but  one 
kidney  is  affected,  a  nephrectomy  being  indicated  in  all  cases. 
Drugs  have  no  place  in  the  treatment. 


DISEASES   OP   THE   GENITOURINARY   SYSTEM.  491 

ENURESIS. 

Synonyms. — Bed-wetting ;  incontinence  of  urine. 

Definition. — This  is  a  continuance  of  the  infantile  habit  of 
vesical  incontinence  into  the  third  year. 

Etiology. — The  control  of  the  bladder  is  a  complex  phe- 
nomenon. AVith  distension  of  the  bladder  the  impulse  for 
evacuation  passes  from  the  nerves  in  the  bladder  wall  to  the 
cord  and  brain,  and  the  impulse  to  the  muscles  of  the  bladder 
is  carried  back  through  the  nerves;  this  causes  relaxation  of 
the  vesical  sphincter,  and  the  contraction  of  the  muscles  of  the 
bladder  follows. 

Enuresis  occurs  in  various  organic  diseases  of  the  central 
nervous  system;  from  irritation  of  the  nervous  centers,  in  the 
cord  or  brain,  and  of  the  nerves  in  the  bladder;  inflammatory 
change  in  the  bladder  mucous  membrane;  congenital  bladder 
malformations ;  abnormal  urine,  especially  a  hyperacidity ;  too 
free  taking  of  fluids  at  bed  time ;  vesical  calculus ;  phimosis ; 
urethritis;  vulvovaginitis  and  urethritis;  extreme  nervous  con- 
ditions, especially  chorea ;  anemia ;  constipation ;  weakness  of 
the  sphincter  vesicae. 

The  oldest  child  I  have  seen  with  enuresis  was  a  boy  of 
13.  Enuresis  may  be  nocturnal  or  occur  only  during  the  day, 
or  may  occur  both  day  and  night. 

Symptoms. — The  chief  symptom  is  the  involuntary  passage 
of  urine,  which  may  occur  once  or  several  times  during  the 
night.  If  it  occurs  only  during  the  day  the  child  may  be  able 
to  retain  the  urine  only  an  hour  or  so.  Frequently  an  acci- 
dental passage  of  urine  occurs  while  the  child  is  intent  upon 
its  play,  and  this  should  not  be  classed  as  an  enuresis. 

The  habit  may  continue  until  puberty,  if  treatment  is  not 
instituted. 

Prognosis. — The  earlier  the  treatment  is  begun,  the  better 
the  results;  the  correction  of  malformations  yields  prompt  re- 
sults. If  there  is  an  organic  brain  lesion  the  prognosis  is  not 
good. 

Treatment. — Examine  carefully  into  any  cause,  mechanical 
or  otherwise,  which  is  removable,  and  first  correct  this.  Usually 
no  other  treatment  is  needed.     Reflection  of  the  prepuce  or  cir- 


492  THE   DISEASES   OP    CHILDREN, 

cumcision  in  severe  phimosis  relieves  one  source  of  irritation, 
and  while  of  itself  does  not  cure  many  cases,  is  a  great  help. 
Build  up  the  child;  correct  dietary  indiscretions;  limit  the 
amount  of  water  drank  after  6  o'clock  in  the  evening;  awaken 
the  child  at  10  o'clock  to  empty  the  bladder;  assist  it  to  sleep 
upon  the  side  and  not  upon  the  back  by  wearing  a  knotted 
towel  about  the  waist  with  the  knot  in  the  lumbar  region;  raise 
the  foot  of  the  bed  to  cause  the  urine  to  distend  the  summit 
of  the  bladder  and  not  make  undue  pressure  upon  its  neck; 
cool  bathing,  followed  by  a  rub,  is  beneficial  also.  A  bland  diet, 
especially  at  night,  should  be  insisted  on. 

Medicinally  belladonna  gives  the  best  results,  and  it  can  be 
given  in  the  form  of  the  tincture,  the  initial  doses  of  1  drop 
for  each  year  of  age,  three  times  a  day,  increased  a  drop  a  day 
until  the  physiological  effect  is  obtained.  The  dose  is  then 
decreased  10  per  cent  and  kept  at  this  for  a  week  or  so,  then 
decreased  1  drop  a  day  until  it  is  discontinued. 

Hexamethylenamine,  salol  or  citrate  of  potassium  may  be  of 
benefit.  Ergot  in  small  doses  is  of  value  in  cases  due  to  weak 
bladder  muscle,  five  minims  of  the  fluid  extract  three  times 
a  day  to  a  child  five  years  old. 

Atropia  can  be  given  as  follows : 

IJ  Atropise   siilpliatis  gr.  ss 

Aquae  destillat  ^i 

M.  et  ft.  solutio. 
Sig.     One  drop  for  each  year  of  the  child's  age  at  4,  5  and  6  o'clock  in 
the  evening.     Strychnia  can  be  added  to  the  above  prescription  in  proper 
dose. 

PHIMOSIS. 

A  congenital  phimosis,  or  contracted  prepuce,  exists  in  all 
male  children,  but  with  the  growth  of  the  glans  penis,  the  adhe- 
sions are  loosened  and  the  accumulation  of  smegma  behind  the 
corona  glandis  separates  them  at  this  point. 

If  from  birth  to  the  fourth  week  the  prepuce  is  pushed  back 
a  little  farther,  daily,  by  the  end  of  that  time  it  can  be  easily 
pushed  back  over  the  corona  glandis  and  the  smegma  removed. 
This  preliminary  and  complete  stretching  and  reflection  dilates 
the  prepuce  sufficiently  to  make  the  complete  uncovering  of  the 


DISEASES   OP    THE   GENITOURINARY   SYSTEM.  493 

glans  easy,  and  obviates  the  necessity  for  circumcision.  This 
reflection  should  be  repeated  once  a  week,  some  vaseline  placed 
behind  the  corona  and  on  the  glans  and  the  foreskin  replaced. 
The  necessity  for  replacement  of  the  foreskin  promptly  after 
its  reflection  should  always  be  borne  in  mind  as  a  paraphimosis 
is  easily  produced. 

Symptoms. — There  may  be  no  symptoms  except  pain  on  void- 
ing urine  or  straining  at  that  time  without  pain.  The  straining 
may  be  so  great  as  to  cause  a  prolapse  of  the  rectum.  Reflex 
symptoms  are  not  uncommon  when  adhesions  are  present.  I 
have  seen  one  boy  presenting  symptoms  of  hip- joint  disease 
which  were  completely  relieved  after  the  preputial  adhesions 
were  broken  up.  Night  terrors  and  epileptiform  convulsions 
may  be  caused  by  phimosis  as  well  as  choreic  symptoms. 
Enuresis  has  been  attributed  to  phimosis,  but  other  observers 
report  little  relief  from  this  condition  by  circumcision  or  cor- 
rection of  the  trouble  by  reflection  of  the  prepuce. 

Treatment. — None  of  these  symptoms  will  present  if  early 
retraction  is  done,  but  if  there  is  a  pin-point  preputial  orifice 
which  is  very  tight  a  circumcision  should  be  done,  with  the 
entire  removal  of  the  prepuce.  A  dorsal  incision  of  the  prepuce 
should  never  be  performed  in  lieu  of  a  circumcision. 

PARAPHIMOSIS. 

This  usually  occurs  in  infants  as  the  result  of  a  reflection 
of  the  prepuce,  the  foreskin  being  allowed  to  remain  behind  the 
corona  glandis  too  long.  As  a  result  a  strangulation  occurs, 
and  a  swelling  of  the  folds  of  the  prepuce  quickly  takes  place. 
The  swelling  may  be  very  great,  the  skin  and  mucous  membrane 
become  reddened,  and  later  may  become  black  if  the  condition 
is  not  relieved.  Considerable  pain  is  present  and  there  may  be 
difficultj^  in  urination. 

Treatment. — Manipulation  may  succeed  in  reducing  the 
deformity.  The  penis  is  encircled  just  back  of  the  corona 
glandis  by  the  fingers  of  one  hand  and  the  other  holds  the 
glans,  firm  pressure  being  made  simultaneously  for  several 
minutes.  The  position  of  the  hands  is  then  changed  and  pres- 
sure is  made  upon  the  glans  and  corona  glandis  by  the  thumbs 


494  THE  DISEASES  OP   CHILDREN. 

and  index  fingers,  an  attempt  being  made  at  the  same  time  by 
the  other  fingers  to  draw  the  foreskin  forward. 

If  these  manipulations  fail,  while  the  penis  is  flaccid  and 
much  of  the  blood  has  been  forced  out  by  the  manipulations, 
the  constricting  bands  are  divided  on  the  dorsum  of  the  penis 
in  the  median  line,  the  reduction  then  being  easily  accomplished. 

HYDROCELE. 

Definition. — An  accumulation  of  serum  in  the  sac  surround- 
ing the  testicle  or  in  the  peritoneal  extension  in  canal  of  Nuek 
of  the  female.     It  may  be  congenital  or  acquired. 

Symptoms. — In  hydrocele  of  the  tunica  vaginalis  there  is  a 
gradual  enlargement  of  one  side  of  the  scrotum,  occasionally  of 
both  sides.  The  tumor  is  tense,  fluctuation  can  be  demonstrated, 
it  is  translucent,  and  can  not  be  reduced  into  the  abdominal 
cavity. 

The  congenital  variety  is  reducible,  the  opening  at  the  internal 
ring  being  patent. 

Treatment. — No  treatment  may  be  needed,  the  fluid  being 
spontaneously  absorbed.  When  very  tense  aspiration  should  be 
performed,  the  inside  of  the  sac  wall  being  rubbed  with  the 
point  of  the  canula,  and  an  obliterative  traumatic  inflammation 
set  up.  The  practice  of  injection  of  carbolic  acid  into  the  sac 
is  not  to  be  commended  in  children. 

BALANITIS. 

This  is  an  inflammation  of  the  mucous  membrane  covering 
the  prepuce  and  glans  penis. 

Etiology. — Neglect  of  the  foreskin,  uncleanliness,  infection, 
trauma,  masturbation,  urethritis  with  confining  of  the  secre- 
tions, and  decomposition  of  the  smegma.  It  occurs  most  often 
in  a  phimosis. 

Symptoms. — The  first  symptom  noted  will  be  an  enlargement 
of  the  penis,  principally  near  the  end  of  the  foreskin.  If  there 
is  a  phimosis  the  end  of  the  prepuce  seems  smaller  than  usual. 
A  discharge  may  be  noticed,  in  the  absence  of  a  urethritis,  com- 
ing entirely  from  the  mucous  membrane  of  the  prepuce  and 
glans.     It  may  be  due  to  a  decomposition  of  the  smegma,  or 


DISEASES  OF   THE   GENITOURINARY  SYSTEM.  495 

an  infection  after  reflection.  I  have  seen  one  case  in  which  a 
small  abscess  formed  behind  the  corona  from  this  cause,  adhe- 
sions having  formed  around  the  pus  and  limiting  it  to  a  small 
area.  Reflection  of  the  prepuce,  breaking  up  of  the  adhesions 
and  cleanliness  caused  a  prompt  cure. 

Treatment. — Perfect  cleanliness  is  indicated.  Boracic  acid 
solution  is  effectual.  Circumcision  should  be  performed  where 
there  is  enough  constriction  to  prevent  free  exposure  of  the  glans 
for  cleansing,  not  however  until  all  inflammation  has  subsided. 
It  may  be  necessary  to  make  a  dorsal  incision  to  accomplish 
free  drainage,  with  a  complete  circumcision  later. 

URETHRITIS. 

This  is  an  infection  of  the  urethra,  and  may  be  simple,  due 
to  the  ordinary  pus-producing  organisms,  or  specific,  due  to  an 
infection  wdth  the  gonococcus.  A  bacteriologic  examination  may 
be  necessary  to  make  the  differential  diagnosis.  It  may  affect 
both  male  and  female  babies,  but  is  more  common  in  older 
children. 

The  simple  form  is  rarely  severe.  There  is  an  invasion  of 
the  urethra  from  a  balanitis,  or  a  simple  vulvovaginitis.  In  the 
male  the  infection  is  usually  limited  to  the  anterior  urethra 
or  the  fossa  navicularis.  Combined  with  a  balanitis  the  condi- 
tion is  much  more  serious.  There  is  pain  on  urination,  the 
child  shrinking  from  a  voluntary  passage  of  urine.  The  dis- 
charge is  not  very  profuse  or  the  duration  of  the  inflammation 
very  long. 

Treatment. — Hexamethylenamine  by  the  mouth  for  the  pur- 
pose of  rendering  the  urine  bland  and  unirritating,  plenty  of 
water  drank,  is  about  all  that  is  needed.  No  local  treatment  is 
indicated  as  a  rule.  In  obstinate  cases  it  may  be  necessary  to 
use  an  application  of  a  5  per  cent  argyrol  solution. 

Gonorrheal  Urethritis.— Unfortunately  this  form  of  infection 
is  met  oftener  than  is  the  general  belief.  It  not  only  occurs 
among  the  poor,  who  live  in  unclean  and  unhygienic  surround- 
ings, but  in  the  children  of  the  well-to-do,  who  may  employ  a 
nurse  who  has  the  infection  and  is  guilty  of  abnormal  practices 
with  the  child,  or  may  be  transmitted  through  the  medium  of  a 


496  THE   DISEASES   OP    CHILDREN. 

towel  or  wash  cloth.  It  occurs  in  boys  most  often  between  six 
and  ten  years  of  age. 

Diagnosis. — The  only  safe  diagnosis  is  by  examining  the 
stained  urethral  discharge  under  the  microscope.  All  urethral 
discharges  should  be  examined  in  this  way  for  diagnosis. 

Symptoms. — A  profuse,  thick,  creamy  discharge  from  the 
urethra  is  present.  There  is  pain  on  urinating,  which  may  only 
be  at  the  passage  of  the  first  few  drops,  or  accompanied  by 
severe  tenesmus  upon  the  completion  of  urination.  The  penis 
is  usually  swollen  and  tender. 

The  chief  complication  to  be  feared  is  conjunctivitis  because 
of  the  carelessness  of  the  child.  Orchitis,  epididymitis  and 
arthritis  are  uncommon  in  children. 

Treatment. — This  does  not  differ  in  any  essential  from  a 
specific  urethritis  in  an  adult,  except  that  urethral  irrigation 
is  impracticable.  Water,  taken  freely;  hexamethylenamine,  gr. 
iii  to  V,  in  boy  of  six;  santal,  5  min.,  will  be  found  of  service. 
A  balanitis,  complicating,  also  demands  attention. 

In  the  specific  cases  the  gonococcus  vaccines  may  be  used  with 
benefit. 

Attendants  should  be  warned  against  the  possibility  of  infec- 
tion of  the  eyes  by  the  discharge. 

VULVOVAGINITIS. 

This  is  an  inflammation  of  the  mucous  membrane  of  the 
vulva,  with  secondary  involvement  of  the  urethra,  vagina  and 
possibly  the  cervix.  It  is  simple  or  specific,  the  latter  due  to 
gonorrhea. 

Etiology. — The  simple  form  is  usually  due  to  uncleanliness ; 
using  the  same  napkin  several  times  after  it  is  wet  before  it  is 
washed;  pin- worms,  or  other  infection  from  the  rectum  as  the 
colon  bacillus ;  the  exanthemata ;  in  institutions  where  the  same 
towel  is  used  by  a  number  of  children ;  trauma  and  masturbation. 

The  specific)  form  is  due  to  an  infection  by  the  gonococcus,  of 
Neisser,  and  in  every  ease  of  vulval  inflammation  the  discharge 
should  be  carefully  stained  and  examined  microscopically.  It 
is  usually  conveyed  by  a  towel  or  washcloth,  infected  by  an 
adult,    similarly   affected.     A   mother   may   innocently    have    a 


DISEASES   OP   THE  GENITOURINARY  SYSTEM.  497 

latent  gonorrhea,  cervical  or  vaginal,  and  infect  the  child  direct 
through  the  medium  of  the  hands.  I  have  had  three  cases  re- 
cently. In  one  the  father,  in  another  the  brother  had  an  acute 
attack  at  the  time  and  infected  a  towel,  in  the  second  the  closest 
questioning  has  failed  to  reveal  the  source  of  contagion,  though 
a  colored  nurse  was  strongly  suspected. 

Symptoms. — The  simple  form  may  present  few  if  any  symp- 
toms, except  a  discharge.  This  may  amount  to  very  little,  save 
a  slight  staining  of  the  clothes.  The  vulva  may  be  slightly 
congested,  but  usually  this  is  not  at  all  severe. 

Glandular  enlargement  in  the  groin  may  be  noticed,  with 
or  without  pain. 

In  the  gonorrheal  form  the  process  is  rarely  limited  to  the 
vulva,  the  invasion  of  the  vagina  and  cervix  being  usual,  as 
well  as  of  the  urethra,  evidenced  by  tenesmus,  frequent  passage 
of  urine  or  a  desire  to  do  so.  There  is  a  burning  and  itching. 
The  discharge  is  quite  thick  and  creamy,  there  is  apt  to  be  a 
sticking  together  of  the  labia,  and  an  accumulation  of  pus  in 
the  ostium  vagina.  After  a  time  there  is  no  pain  or  discomfort, 
the  only  thing  being  the  disagreeable  discharge  of  pus.  There 
usually  is  an  enlargement,  sometimes  painful,  of  the  inguinal 
glands,  which  may  keep  the  child  from  walking  or  crawling. 

The  specific  form  lasts  longer  than  the  simple,  usually  from 
four  to  six  Weeks.  The  last  case  I  had  under  my  observation 
was  in  the  two-year-old  child  of  a  most  intelligent  and  faithful 
mother,  with  a  persistence  of  the  discharge  for  nearly  seven 
weeks.  The  examination  of  some  of  the  secretion  about  the 
vulva  is  the  only  way  that  the  progress  of  the  case  can  be  reck- 
oned. 

Complications. — Atresia  of  the  vagina  may  occur;  conjunc- 
tivitis, orchitis,  epididymitis,  inflammation  of  the  glands  of 
Bartholin,  arthritis,  inguinal  adenitis,  salpingitis,  peritonitis. 

Prognosis. — This  is  good,  but  the  duration  is  usually  longer 
than  in  the  simple  form,  averaging  four  weeks  and  often  much 
longer.  Diagnosis  can  only  be  made  by  a  microscopic  examina- 
tion of  the  pus  and  should  be  done  early. 

Treatment. — The  vulva  and  vagina  should  be  carefully  irri- 
gated wdth  a  1 :5000  bichloride  of  mercury  solution,  followed 


498  THE  DISEASES  OP    CHILDREN. 

by  a  solution  of  nitrate  of  silver,  2  per  cent;  Argyrol,  2  to  5 
per  cent  solution,  can  be  used  instead  of  the  nitrate  of  silver. 
Extra  precautions  should  be  taken  to  limit  the  possibility  of 
an  infection  of  the  eyes,  as  this  is  apt  to  take  place  unless  most 
careful  precautions  are  taken. 

The  inoculation  treatment  of  specific  vulvovaginitis  has  been 
used  with  some  success.^ 

The  patient's  opsonic  index  is  taken  every  other  day  accord- 
ing to  Wright's  method.  At  first  the  index  should  be  compared 
with  that  of  several  healthy  boys. 

The  tolerance  for  the  vaccine  by  the  different  patients  varies, 
but  an  average  of  1,000,000  is  given  and  increased  according 
to  the  index  gonococcus.  Local  reaction  usually  takes  place  at 
the  site  of  injection,  as  an  indurated  tender  area.  A  geijeral 
reaction  is  rarely  seen.  The  injections  are  given  every  fifth 
or  sixth  day  and  should  be  guided  by  the  index.  The  conclusions 
reached  from  observation  of  a  large  number  of  cases  is  that 
the  vaccine  treatment  shortens  the  duration  of  an  attack;  that 
old  strains  are  more  effective  than  fresh  ones;  that  the  serum 
treatment  is  not  to  be  recommended. 

The  diet  should  be  unirritating  and  nourishing;  water  taken 
freely  between  feedings. 

Because  of  the  possibility  of  involvement  of  the  scrotum  and 
contents  in  male  infants,  the  child  should  be  kept  in  bed  entirely 
during  the  acute  stage. 

Treatment  should  be  continued  as  long  as  there  is  any  dis- 
charge, and  discontinued  only  when  no  cocci  are  found  on 
microscopic  examination  of  the  vulval  secretion. 

CYSTITIS. 

This  is  an  inflammation  of  the  mucous  membrane  of  the 
bladder.  It  rarely  occurs  as  a  primary  condition  but  most  fre- 
quently as  a  result  of  a  calculus  in  the  bladder,  or  secondary 
to  a  balanitis  or  urethritis,  the  latter  usually  of  specific  origin. 
It  may  be  due  to  a  direct  invasion  of  the  colon  bacillus. 

Symptoms. — There  is  a  distinct  history  of  frequent  and 
nearly  always  of  painful  micturition,  which  has  lasted  a  variable 
length  of  time.     Mild  cases  may  not  complain  of  pain.     There 


*  Churchill- Soper:   Journal   American    Medical    Association,    vol.    li,    no.    10. 


DISEASES   OP   THE   GENITOURINARY   SYSTEM.  499 

may  be  pain  in  the  perineum  of  the  male  and  discomfort  or 
pain  in  the  lower  portion  of  the  abdomen  in  both  sexes. 

The  urine  is  acid  if  the  colon  bacillus  is  present,  cloudy  and 
contains  epithelium  and  pus,  probably  a  trace  of  albumin  and 
many  bacteria.  Blood  is  present  also,  if  there  is  a  mixed 
infection. 

Prognosis. — Prompt  recovery  is  the  rule,  except  when  the  in- 
fecting organism  is  the  gonococcus. 

Treatment. — Usually  rest  in  bed,  milk  diet,  copious  drafts  of 
water  and  hexamethylenamine,  in  from  3  to  5  grain  doses,  is 
all  that  is  needed.  In  very  acute  cases,  with  painful  urination, 
an  anodyne  may  be  needed.  Bladder  irrigation  is  not  always 
necessary;  when  indicated  a  boracic  acid  solution,  1  or  2  ounces 
at  a  time,  can  be  introduced  and  immediately  withdrawn. 

UNDESCENDED  TESTICLE. 
Cryptorchidism. 

During  the  early  months  of  intrauterine  life  the  testicles  rest 
in  the  abdominal  cavity,  postperitoneally,  just  below  the  kid- 
neys. They  pass  downward  and  enter  the  scrotum,  through 
the  inguinal  caual  about  the  ninth  month  of  intrauterine  life. 

The  testicle,  one  or  both,  fails  to  descend  into  the  scrotum  in 
the  proportion  of  about  1  in  500  cases.  It  may  be  interrupted 
in  its  descent  and  remain  in  the  cavity;  lodge  at  the  internal 
ring;  or  it  may  lodge  in  the  inguinal  canal. 

Cases  in  which  the  lodgement  is  in  the  cavity  demand  no  inter- 
ference, but  those  which  lodge  at  the  internal  ring  or  in  the 
canal  the  indication  for  interference  is  present,  as  the  organ 
may  become  injured;  inflammatory  conditions  of  the  cord  and 
testicle  are  more  apt  to  occur,  and  hernias  prone  to  develop. 

For  the  relief  of  this  condition  Bevan  ^  has  suggested  opera- 
tive procedures  as  follows :  An  incision  3  inches  long  over  the 
inguinal  canal  dividing  skin,  fascia  and  external  oblique 
aponeurosis.  A  pouch  of  peritoneum  is  found  under  the  exter- 
nal oblique  extending  from  the  abdominal  peritoneum  through 
the  canal  to  the  scrotum,  even  in  cases  in  which  the  testicle 
has  remained  in  the  cavity.     The  pouch  of  peritoneum  is  opened, 

*  Keen's   Surgery,   vol.    iv. 


500  THE  DISEASES  OF   CHILDREN. 

cutting  through  the  thin  layers  of  cremasteric  muscle  and  fascia 
and  transversalis  fascia.  Transverse  division  of  the  vaginal 
process  is  made  above  the  testicle  and  the  upper  end  closed  with 
catgut.  The  lower  end  wnth  a  purse-string  suture,  thus  making 
a  tunica  vaginalis  for  the  testicle.  The  peritoneum  is  wiped 
from  the  cord  with  a  sponge,  and  the  fibrous  strands  in  the 
cord  torn  with  fingers  or  forceps,  the  cord  being  freed  of  every- 
thing but  the  vas  and  vessels.  If  the  testicle  will  not  reach 
to  the  bottom  of  the  scrotum,  it  maj'  be  necessary  to  ligate  and 
cut  the  spermatic  artery  and  veins.  Blunt  dissection  of  the 
peritoneal  pouch  with  the  finger  may  be  necessary  to  allow  the 
testicle  to  be  pushed  in,  where  it  is  retained  by  a  purse-string 
suture  within  the  neck  of  the  scrotum.  The  wound  is  then 
closed  as  in  any  hernia  operation. 

The  age  for  performance  of  this  operation  is  between  5  and 
12  years  of  age. 


CHAPTER  XXI. 

NUTRITIONAL  DISORDERS. 

ATHREPSIA. 

Sjmonyms. — Mdlnidrition;  marasmus;  inanition;  ivasting  dis- 
ease, infantile  atrophy. 

Etiology. — This  condition  develops  most  frequently  as  a 
sequel  to  the  acute  gastrointestinal  disorders,  in  which  the  di- 
gestive disturbance  becomes  chronic. 

It  is  characterized  by  atrophy  of  the  tissues  and  a  progressive 
loss  in  weight  and  strength.  Heredity  plays  an  important  role 
in  the  etiology.  Weak  and  delicate  parents  have  poorly  resisting 
offspring. 

Environment  is  a  decided  causative  factor.  Children  in  over- 
crowded tenement  districts,  with  badly  ventilated  sleeping  quar- 
ters, who  get  but  little  fresh  air  and  have  poorly  prepared  food, 
are  liable  to  develop  this  condition. 

The  most  important  cause  is  the  food.  The  food  itself  may 
be  all  right  but  its  mode  of  preparation,  method  of  administra- 
tion and  quantity  may  result  in  an  intestinal  intoxication  with 
resultant  malnutrition. 

It  usually  begins  after  the  sixth  month  of  life,  and  reaches 
its  height  before  the  second  year,  if  the  child  survives  this  long. 
It  is  rarely  seen  among  children  who  are  breast  fed. 

"Hospitalism"  is  sometimes  the  cause.  For  some  unknown 
reason  a  child  may  not  do  well  in  an  orphan  asylum,  and  if  its 
surroundings  and  environment  are  changed  without  change  of 
diet  they  do  well. 

Pathology. — There  is  no  distinct  pathology  to  this  condition; 
coincident  with  the  general  atrophy  and  wasting  of  the  tissues 
there  is  an  atrophy  of  the  glandular  structure  of  the  digestive 
tract.  There  is  a  condition  of  lymphatism,  an  enlargement  of 
all  the  lymph  nodes  of  the  body,  especially  of  the  mesentery,  soli- 
tary glands  of  the  intestines  and  the  bronchial  glands. 

501 


502  THE   DISEASES   OF   CHILDREN. 

The  subcutaneous  fat  is  absorbed  and  the  skin  of  the  body 
is  wrinkled  and  lies  in  folds.  As  the  condition  progresses,  the 
skin  of  the  face  becomes  tightly  drawn  over  the  bones  and  the 
child  assumes  the  old-man  appearance  which  is  so  characteristic. 
Hemorrhages  may  occur  in  the  skin  or  the  mucous  membranes, 
especially  of  the  intestines. 

Symptoms. — In  every  case  of  acute  gastrointestinal  disorder 
the  possibility  of  its  terminating  in  a  condition  of  athrepsia 
should  be  borne  in  mind,  and  the  child  put  on  a  gaining  diet  at 
the  first  possible  moment,  without  overtaxing  the  digestive  capac- 
ity. The  child's  weight  is  the  best  guide  as  to  the  importance 
of  this.  A  progressive  loss  in  weight  each  week  is  an  indication 
for  increased  watchfulness. 

Athrepsia  is  essentially  an  insidious  condition,  reaching  an 
alarming  proportion  in  a  period  extending  over  several  months. 

There  is  a  progressive  loss  in  weight;  the  subcutaneous  fat 
disappears  and  the  skin  lies  in  folds;  it  is  harsh  and  dry  to 
the  touch ;  the  abdomen  soon  becomes  distended  from  accumu- 
lation of  gas  in  the  stomach  and  intestines,  principally  in  the 
colon.  It  is  restless  and  irritable,  crying  or  whining  con- 
stantly; the  temperature  is  apt  to  be  subnormal,  with  occasional 
rise,  from  an  intercurrent  intestinal  toxemia  or  indigestion. 

The  bowels  are  apt  to  be  constipated;  but  thin  mucus  move- 
ments are  occasionally  seen.  It  is  rare  that  two  actions  passed 
are  of  the  same  color  or  consistence.  They  are  more  often  green 
than  of  the  normal  color,  and  frequently  contain  undigested 
particles  of  food,  and  are  universally  of  a  foul,  putrefactive  odor. 

Because  of  the  irritating  character  of  the  discharges  the  skin 
of  the  buttocks  develops  an  intertrigo;  it  is  red,  thickened,  and 
may  become  moist  if  it  breaks  down. 

Dentition  is  delayed  and  a  stomatitis  is  apt  to  occur;  the 
tongue  is  usually  dry,  cracks  develop  at  the  corners  of  the  mouth. 

The  child  will  usually  act  as  if  famished,  and  will  take  eagerly 
any  food  or  water  which  is  given.  Vomiting  is  frequently  pres- 
ent, chiefly  owing  to  the  rapidity  with  which  food  is  taken  and 
the  over-distending  of  the  stomach.  Dilatation  of  this  organ 
quite  regularly  results. 

Diagnosis. — The   differentiation    of   athrepsia   from   the    less 


NUTRITIONAL   DISORDERS.  503 

serious  forms  of  malnutrition  is  difficult,  as  there  is  no  fine-cut 
line  of  difference.  It  must  be  differentiated  from  tuberculosis 
and  congenital  syphilis.  In  the  former  there  is  apt  to  be  a 
rise  in  temperature,  probably  with  signs  in  the  chest  if  of  that 
form.  The  localization  of  tuberculosis  in  any  organ  or  struc- 
ture should  make  the  diagnosis  easier.  The  enlargement  of  the 
h'mph  nodes  in  both  forms  makes  this  occurrence  of  no  assist- 
ance as  a  diagnostic  sign. 

In  congenital  syphilis  the  changes  in  the  skin  and  mucous 
membranes,  snuffles,  historj'-  and,  as  a  rule,  earlier  development 
of  sj'mptoms  assist  in  the  differentiation. 

Prognosis. — The  condition  is  invariably  a  grave  one,  espe- 
cially in  the  severer  forms  of  the  trouble.  Where  hospitalism 
is  a  feature  the  results  are  universally  bad. 

The  condition  is  progressive  and  a  fatal  result  almost 
inevitable. 

Treatment. — A  most  careful  inquiry  must  be  made  into  the 
routine  of  the  child's  life,  its  feeding  from  birth,  with  details 
of  the  various  changes  in  the  diet,  and  a  record  made  of  the 
character,  of  preparation  and  quantity  of  the  food  given.  This 
is  most  essential  as  the  diet  is  so  often  at  fault  primarily. 

If  its  environment  and  surroundings  are  at  fault  these  must 
be  changed.  If  hospitalism  is  present,  endeavor  to  have  the 
child  placed  in  a  private  family  or  isolated  in  larger  quarters 
with  more  air  available.  A  change  of  climate  is  often  of  great 
benefit  in  children  in  private  homes. 

Regular  bathing,  bran  baths,  salt  rubs,  olive-oil  rubs,  after 
the  water  baths ;  careful  attention  to  the  skin  of  the  buttocks, 
and  to  the  napkins  and  feeding  apparatus ;  plenty  of  out-of-door 
air;  attention  to  the  mouth,  with  frequent  use  of  a  boracic  acid 
mouth  wash.  The  most  important  consideration  is  of  the  food, 
which  must  be  regulated  as  soon  as  the  gastrointestinal  tract 
has  been  placed  in  as  normal  a  condition  as  possible.  This  is 
brought  about  by  giving  an  initial  dose  of  calomel,  gr.  i  in  Vs 
gr.  doses,  repeated  at  half-hour  intervals,  and  followed  by  a 
dose  of  oil. 

If  on  the  breast  the  milk  must  be  examined  and  the  deficien- 
cies in  it  corrected  by  artificial  feeding,  or  a  suitable  wet-nurse, 


504  THE  DISEASES   OF    CHILDREN. 

if  possible.  A  preliminary  examination  of  the  milk  of  the  wet- 
nurse  must  be  made. 

If  on  a  modified  milk,  this  should  be  withdrawn  until  after 
the  preliminary  cleaning  out  of  the  intestinal  tract,  a  dextrin- 
ized  barley  water  being  temporarily  given. 

A  modified  milk,  low  in  fat  percentage,  should  be  given  at 
first,  and  in  small  quantities  at  two-hour  intervals.  As  the 
child  evidences  an  abilitj'^  to  take  care  of  the  food  it  can  be 
increased  both  in  strength  and  quantity.  The  stools  must  be 
closely  watched. 

The  importance  of  obtaining  a  certified  milk,  or  milk  of  equal 
cleanliness,  should  be  emphasized.  Whey  is  a  valuable  food 
to  be  used  during  the  period  of  getting'  the  child  on  to  a  gain- 
ing diet. 

A  prescription  as  follows  can  be  used  to  advantage  at  first: 
Fat  0.5  to  1.0,  sugar  6.0,  and  proteid  0.5  to  1.0,  the  proteid 
increased  slightly  more  rapidly  than  the  fat  as  the  child  shows 
evidence  of  ability  to  care  for  it. 

The  tendency  is  to  give  these  babies  cod  liver  oil  or  olive 
oil,  to  bring  up  the  fat  deposit  in  the  system,  but  it  should  be 
given  with  great  caution.  Fats  are  poorly  taken  care  of  in 
the  intestine,  and  the  intestine  can  be  easily  overwhelmed,  with 
these,  if  given  in  addition  to  the  regular  diet.  Lavage  can  be 
used  in  the  obstinate  vomiting  cases,  and  gavage  in  those  cases 
in  which  vomiting  continues  in  spite  of  stomach  washing. 

The  advantage  of  using  partially  or  completely  peptonized 
milk  in  the  beginning  of  these  cases  should  be  borne  in  mind, 
but  should  not  be  too  long  continued. 

Tonics  have  their  place  in  the  treatment  of  this  condition; 
as  minute  doses  of  strychnia,  iron,  diastatic  agents,  as  pancrea- 
tine, etc.,  and  stimulants,  in  certain  cases  may  be  indicated. 

SCORBUTUS. 

Synonyms. — Infantile  scurvy ;  Barlow's  Disease. 

This  is  a  constitutional  nutritional  disease  due  to  prolonged 
error  in  diet.  Hemorrhages  are  its  chief  manifestation,  and 
these  may  be  in  the  joints,  under  the  periosteum  or  from  the 
mucous  and  serous  membranes,  and  in  the  tissues. 

Etiology. — This  is  particularly  a  disease  of  infancy,  being 


NUTRITIONAL   DISORDERS.  505 

seen  most  often  before  the  second  year  of  age,  rarely  before  the 
fourth  month.  The  diet  is  the  chief  cause,  viz.,  prolonged  use 
of  one  of  the  artificial  foods,  condensed  milk,  cow's  milk  in 
improper  modifications,  which  usually  has  been  Pasteurized  or 
sterilized.  Isolated  cases  have  been  reported  as  developing  in 
children  who  have  been  on  breast  milk  exclusively.  These  have 
been  rare,  however.  The  continued  use  of  any  food  which 
lacks  the  vital  quality  of  freshness,  will  cause  scurvy. 

Pathology. — The  chief  changes  are  in  the  blood  vessels  which 
permit  of  the  escape  of  blood  into  the  joints  or  tissues,  or  a 
changed  blood  which  can  escape  from  more  or  less  normal  blood 
vessels.  The  chief  hemorrhages  seen  are  under  the  periosteum 
of  the  long  bones,  principally  of  the  lower  extremities,  in  the 
joints,  from  the  mucous  membranes,  and  in  the  subcutaneous 
tissues.  The  bones  of  the  arms  are  less  often  affected,  but 
hemorrhages  do  occur  at  the  ends  of  the  ribs  and  on  the  scapula 
and  sternum. 

Numerous  ecchymotic  spots  appear  in  the  skin  of  the  body. 
The  mucous  membrane  around  the  teeth  and  of  the  gums, 
becomes  spongy  and  bleed  if  touched.  The  teeth  may  become 
loosened. 

Symptoms. — The  child  usually  gives  a  history  of  doing  badly 
for  several  weeks,  is  pale  and  anemic  and  more  restless  than 
usual.  Suddenly,  if  it  has  been  walking,  it  refuses  to  stand, 
and  cries  when  handled.  The  joints  become  swollen  and  very 
tender,  and  there  may  be  pain  when  the  child  is  entirely  quiet, 
but  this  is  not  usually  the  case.  Examination  of  the  legs  reveals 
swellings  along  the  shaft  of  the  long  bones  and  near  the  epiph- 
yses, and  the  joints  are  swollen,  usually  without  redness. 

The  skin  may  show  a  number  of  hemorrhagic  spots,  like 
bruises,  some  large,  or  there  may  be  a  number  of  petechial 
spots  scattered  over  the  body.  Characteristic  changes  occur  in 
the  mouth.  The  gums  are  spongy  and  usually  extend  some  dis- 
tance up  on  the  teeth,  and  they  bleed  on  the  slightest  touch. 
The  gums  may  not  break  down,  if  no  teeth  are  present,  but  the 
mucous  membrane  over  them  usually  shows  a  number  of  small 
hemorrhagic  areas. 

Meleno,  may  be  present  and  blood  in  the  urine  is  not  uncom- 


506  TUE  DISEASES  OF   CHUiDREN. 

mon,  with  blood  casts  and  albumin  present  also.  A  single  or 
double  exophthalmos  due  to  blood  in  the  orbit  may  be  present, 
but  this  is  not  at  all  a  constant  symptom.  A  subconjunctival 
hemorrhage  sometimes  occurs.  Discoloration  of  the  skin  around 
the  eye,  a  so-called  ''black  eye,"  is  often  present,  especially 
when  there  is  an  exophthalmos.  Hematuria  is  not  infrequently 
present.  In  regard  to  the  blood  count  in  scurvy,  Da  Costa 
reports,  as  a  result  of  examination  of  seven  cases,  an  average 
hemoglobin  percentage  of  43  per  cent,  an  average  of  red  cells 
of  3,527,000,  the  average  leucocytes  of  15,500.  In  only  one 
of  the  seven  cases  was  there  a  leucocytosis. 

Diagnosis. — The  chief  trouble  to  be  diagnosed  from  is  7'Jieii- 
matism.  I  have  seen  three  such  cases,  each  had  been  vigorously 
treated  for  rheumatism,  and  each  presented  the  classical  symp- 
toms of  scurvy.  If  the  chief  pathological  conditions  of  scurvy 
are  borne  in  mind  the  diagnosis  is  plain,  as  a  rule,  viz.,  hemor- 
rhages under  the  periosteum  and  in  the  joints,  and  the  typical- 
changes  in  the  gums.  Owing  to  the  forced  immobility  from 
the  pain  in  the  joints  the  legs  have  the  appearance  of  being 
partially  or  completely  paralyzed.  The  muscles  are  tense,  to 
protect  the  leg,  and  have  none  of  the  true  appearance  of  a 
paralysis.  Occasionally  there  is  a  rise  of  temperature,  but  it  is 
irregular  and  rarely  high.  Among  the  other  conditions  which 
may  be  mistaken  for  scurvy  are  as  follows;  periosteitis,  osteo- 
myelitis, hip  disease,  injury,  difficult  dentition,  infantile 
paralysis. 

Prognosis. — This  is  universally  good  if  the  condition  is  recog- 
nized early  and  appropriate  treatment  begun.  Even- the  hemor- 
rhages causing  the  exophthalmos  are  quickly  absorbed.  Delay 
in  the  diagnosis  prolongs  convalescence  proportionately  long. 

Treatment. — This  is  essentially  one  of  diet,  no  medication 
being  required.  Inquiry  should  be  made  in  detail  in  regard 
to  the  feeding,  and  it  should  be  taken  off  all  proprietary  foods, 
and  put  on  fresh,  unsterilized  and  unpasteurized  cow's  milk  at 
once.  If  the  child  is  under  one  year,  the  milk  should  be  so 
modified  that  the  fat  and  proteid  contents  are  not  too  high; 
if  over  one  year  of  age  a  4  per  cent  milk  can  usually  be  easily 
taken  care  of. 


NUTRITIONAL   DISORDERS.  507 

In  addition  to  the  milk  the  child  should  be  given  strained 
orange  juice,  which  is  practically  a  specific,  at  first  half  an 
ounce  twice  daily,  between  feedings,  gradually  increased  to 
1^/^  or  2  ounces.  One  or  two  feedings  a  day  of  an  animal  broth, 
or  the  expressed  juice  of  beef,  will  be  found  most  beneficial, 
and  one  feeding  of  a  small,  baked  Irish  potato  daily.  One  or 
two  tablespoonfuls  of  the  beef  juice  can  be  given  alone  or  as 
gravy  over  the  potato. 

Careful  regulation  of  the  hygienic  conditions  should  be  made, 
the  child  kept  in  a  bright,  airy  room,  with  plenty  of  sunshine. 
It  should  be  kept  quiet  and  not  handled  more  than  necessary 
to  keep  it  clean,  and  the  improvement  will  be  decided  in  the 
covirse  of  three  or  four  days. 

Medication  is,  as  a  rule,  not  needed,  except  it  be  to  combat 
the  anemia  which  is  present  in  nearly  all  cases,  especially  if  of 
long  standing  and  it  does  not  respond  to  the  dietetic  treatment. 

Iron  in  some  form  will  be  well  borne: 

IJ  Tinct.  ferri  chloridi  3ii 

Glycerin!  ^ss 

Aquae   destillatse   q.s  Jii 

M.  ft.  Sol.     One  teaspoonful  after  eating,  three  times  a  day. 

The  prevention  of  scurvy  is  of  great  importance.  The  diet  of 
every  artificially-fed  infant  should  receive  careful  supervision, 
proprietary  foods  not  used,  and  the  progress  report  regularly 
sent  in  for  the  guidance  of  the  physician. 

RACHITIS. 

Synonyni. — Rickets. 

This  is  a  constitutional  disease  or  disorder  of  nutrition  in 
which  the  most  striking  changes  are  in  the  bones,  the  principal 
site  being  the  epiphyses,  though  more  or  less  marked  changes 
occur  in  every  other  organ  and  tissue  of  the  body. 

Etiology. — Bad  hygienic  surroundings  and  unsuitable  food 
are  the  principal  causes.  Infants  who  are  breast  fed  well  into 
their  second  year,  or  who  are  getting  a  breast  milk  below  stand- 
ard in  quantity  and  quality,  or  the  artificially  fed  in  whom  the 
proprietary  foods  or  condensed  milk  are  given  to  practically 
the  exclusion  of  fresh  food,  are  prone  to  develop  rickets.     From 


508  THE  DISEASES   OF    CHILDREN. 

this  we  would  scarcely  expect  to  see  a  case  before  the  sixth 
month,  but  cases  of  fetal  rickets  have  been  reported.  In  con- 
densed milk,  and  in  sonie  of  the  proprietary  foods  also,  the  chief 
element  lacking  is  the  fat,  as  in  any  dilution  recommended  the 
fat  content  is  low. 

A  history  may  be  obtained  of  a  previous  exhausting  disease, 
as  a  prolonged  gastrointestinal  disturbance  or  the  exanthemata, 
a  bronchitis  of  some  weeks  duration,  always,  however,  in  con- 
nection with  some  irregularity  in  diet  or  a  failure  to  give  the 
child  a  well-balanced  ration,  which  is  meeting  the  needs  of  its 
nutrition. 

Kickets  is  more  frequently  found  in  the  colored  race  than 
in  any  other,  next  in  frequency  perhaps  in  Italians.  In  both 
these  races  over-crowding,  unhygienic  surroundings  and  im- 
proper food  are  present. 

Pathology. — All  of  the  tissues  of  the  body  share  in  the  nutri- 
tional changes  found,  but  because  of  the  prominence  of  the  bony 
changes  attention  is  chiefly  focused  on  them.  The  bony  changes 
occur  in  the  centers  of  ossification  and  consist  in  the  excessive 
deposit  of  cartilage  at  these  points.  In  the  long  bones  it  is  at 
the  epiphyses,  in  the  flat  bones,  especially  of  the  skull,  it  is  in 
the  center.  Owing  to  the  deficiency  in  the  lime  salts  in  the  carti- 
lage cells  these  fail  to  ossify,  and  all  the  bones  are  soft  and  more 
or  less  flexible;  because  of  this  condition  the  fairly  character- 
istic bony  deformities  of  rachitis  take  place.  Craniotabes  is  a 
characteristic  condition,  being  a  softened  area  to  the  sides 
of  the  occipital  protuberance,  which  can  be  very  easily  demon- 
strated. 

There  is  a  congestion  or  hyperplasia  of  the  periosteum  at  the 
ossification  centers.  It  is  easily  removed  from  the  bone.  Micro- 
scopically a  marked  increase  in  the  new  cartilage  cells  is  seen, 
and  an  increased  vascularity  of  the  proliferating  zone. 

Anemia  is  always  present,  the  hemoglobin  is  relatively  low. 
Morse's^  cases  averaged  63  per  cent  with  a  color  index  of  0.7. 
The  red  cells  in  his  cases  averaged  over  4.500,000. 

Leucocytosis  is  present  in  many  cases,  but  not  in  all  by  any 
means. 


1  Boston  City  Hospital  Rep.,   1897. 


NUTRITIONAL   DISORDERS.  509 

The  muscles  are  flabby,  and  the  ligaments  weak  and  easily 
stretched,  the  heart  is  weak  and  irritable. 

Bronchitis  and  pneumonia  are  frequent  complications,  there 
seeming  to  be  an  almost  constant  state  of  passive  congestion  of 
the  mucous  membranes. 

There  is  an  enlargement  of  both  the  liver  and  the  spleen,  espe- 
cially the  latter.  The  spleen  can  quite  easily  be  palpated  below 
the  costal  margin. 

Symptoms. — Focal. — The  head  of  the  rachitic  child  is  en- 
larged, the  bitemporal  and  biparietal  diameters  are  increased. 
Bosses  develop  at  the  centers  of  ossification,  chiefly  of  the  parie- 
tal and  the  occipital  bones.  The  forehead  is  high,  and  the 
fontanelles  are  both  late  in  closing.  Frequently  the  sutures 
are  found  ununited. 

The  rachitic  rosary  is  a  fairly  constant  symptom.  This  is 
an  enlargement  of  the  ribs  at  their  costal  margin  and  gives  the 
impression  of  a  string  of  beads.  If  these  enlargements  are  of 
some  size  their  under  surfaces  will  make  indentations  on  the 
lungs.  As  a  result  of  the  softening  of  the  costal  cartilage  the 
atmospheric  pressure  pushes  in  this  portion  of  the  chest  wall, 
causing  the  sternum  to  be  more  prominent.  This  deformity  is 
called  a  pigeon  breast,  and  is  fairly  characteristic. 

The  ends  of  the  long  bones  show  an  enlargement,  the  epiph- 
yses at  the  wrist  being  specially  large. 

If  the  child  is  walking,  the  weight  of  the  superimposed  body 
causes  a  bend  in  the  femur  and  bones  of  the  leg,  as  well  as  an 
exaggeration  of  the  curves  of  the  spine.  A  lateral  curvature 
not  unusually  develops.  Genuvalgum,  a  knock-knee,  and  genu- 
varum,  bow-legs,  are  common  deformities.  An  anterior  curva- 
ture of  the  tibiae  is  often  present.  This  is  probably,  in  part, 
at  least,  due  to  the  child  sitting  in  a  chair  with  its  feet  extend- 
ing beyond  the  anterior  edge,  the  weight  of  the  foot  causing 
the  bend  in  the  tibia. 

At  this  stage  of  bony  formation,  softening  of  the  pelvic  bones 
may  result,  in  female  children,  in  a  flattening  of  the  pelvis,  caus- 
ing the  flat  rachitic  pelvis  which  results  in  a  dystocia  in  the 
child-bearing  period. 

Dentition  is  delayed  and  often  difficult.     After  the  teeth  are 


510  THE  DISEASES  OP   CHILDREN. 

cut  they  are  soft  and  decay  early,  the  front  teeth  often  crum- 
bling away. 

Systemic  Sjnnptoms. — An  anemia  appears  early  and  is  fre- 
quently quite  pronounced. 

Owing  to  the  loss  of  tone  of  the  musculature  of  the  stomach 
and  intestines  these  organs  become  distended,  and  the  child  pre- 
sents a  "pot  belly."  Attacks  of  gastroenteritis  are  frequent. 
Constipation  is  the  rule.  These  conditions  are  chiefly  due  to 
the  child  eating  more  than  it  can  digest  and  assimilate. 

Head  sweating  is  an  early  and  prominent  symptom,  and  when 
present  should  cause  the  physician  to  be  suspicious  at  once. 
The  child's  pillow  will  be  wet  whenever  it  lies  down  to  take  its 
nourishment  or  to  sleep,  and  its  hair  quite  wet,  with  beads  of 
perspiration  on  its  forehead  and  neck,  and  this  in  spite  of  the 
temperature  of  the  room. 

It  is  cross  and  irritable,  and  if  muscle  tenderness  is  present 
it  cries  if  it  is  handled  or  moved. 

It  is  very  restless  and  sleep  is  greatly  disturbed ;  it  will  cry 
out  in  its  sleep  very  frequently.  It  is  often  wakened  at  night, 
with  a  spasmodic  condition  of  the  larynx,  causing  a  peculiar 
cro wing-like  sound.  This  is  laryngismus  stridulus  and  is  a 
fairly  constant  diagnostic  sign. 

The  child  is  backward  in  walking,  due  to  the  deficient  muscular 
power,  the  muscles  being  soft  and  flabby.  The  association  of 
adenoids  and  rachitis  is  not  infrequent,  the  child  being  a  mouth 
breather  in  consequence. 

Late  in  the  disease  there  is  a  temperature  of  from  one  to  three 
degrees,  with  acceleration  of  the  pulse  rate.  This  is  due  to  some 
intercurrent  affection,  particularly  bronchitis  or  pneumonia,  or 
gastrointestinal  trouble. 

Prognosis. — Rickets  is  a  chronic  affection,  usually  running 
its  course  in  about  two  years,  if  upon  the  proper  diet  or  treat- 
ment. Because  of  their  weakened  state  and  lack  of  resistance 
rachitic  children  are  more  likely  to  develop  the  acute  exanthe- 
mata,   diphtheria,   whooping-cough,   pulmonary   diseases,   etc. 

Prognosis  is  worse  in  diseases  of  this  nature  in  the  rachitic. 
There  may  be  a  gradual  absorption  of  some  of  the  bony  deposit 
at  the  epiphyses  and  bosses,  but  the  deformities  do  not  disap- 


nutritionaij  disorders.  511 

pear.  The  flat  rachitic  pelvis,  the  genuvarum  and  valgum,  the 
kyphosis,  remain  during  the  life  of  the  child. 

Diagnosis. — In  every  child  not  doing  well  rickets  should  be 
borne  in  mind,  as  its  earliest  symptoms  are  vague  and  might  go 
unrecognized.  But  if  the  principal  symptoms  are  remembered 
the  diagnosis  should  be  easy,  viz.,  head  sweating,  rachitic  rosary, 
enlargement  of  the  epiphyses,  craniotabes,  constipation,  delayed 
dentition,  restlessness  at  night,  anemia,  laryngismus  stridulus 
and  enlarged  abdomen. 

Treatment. — The  principal  indication  is  to  learn  the  cause, 
if  possible,  and  remedy  it.  If  it  is  the  feeding  which  is  at 
fault  it  must  be  carefully  regulated,  fresh  and  properly  modi- 
fied milk  given;  proprietary  foods  must  be  withdrawn;  scraped 
beef  is  of  great  assistance  in  building  up  these  cases.  If  the 
quality  of  the  breast  milk  is  found  at  fault,  with  ample  quantity, 
the  nursings  should  be  shorter  and  the  child  given  a  small  arti- 
ficial feeding  after  nursing  of  a  modified  milk  with  formula 
suited  to  its  needs.  If  on  modified  milk  the  same  formula  may 
be  kept  up  for  too  long  a  period,  and  be  unequal  to  the  demands 
of  nutrition  when  teething  has  begun.     This  is  seen  very  often. 

If  on  a  mixed  diet,  it  may  be  found  the  child  makes  one  or 
two  meals  on  cereals,  heavily  loaded  with  sugar,  drinks  but 
little  milk,  rarely  tastes  meat,  eats  much  potato  and  bread. 
The  proteid  and  fat  in  its  diet  is  greatly  lacking,  and  this  must 
be  regulated  by  the  use  of  milk,  cream,  scraped  beef  and  beef 
juice,  animal  broths,  eggs,  and  of  butter  in  the  older  children. 

Regulation  of  the  child's  surroundings,  cleanliness  and  daily 
routine  of  living  is  of  vast  importance,  if  in  the  crowded  dis- 
tricts of  a  city  they  can't  get  the  fresh  air  so  necessary  to  their 
vitality.  These  children  need  plenty  of  air  and  out-door  sun- 
shine. Fresh  air  must  be  in  the  sleeping  rooms  also.  The  daily 
bath  is  very  necessary,  which  should  be  followed  by  a  cool  sponge, 
especially  over  the  chest  and  back,  for  the  purpose  of  inuring 
them  to  the  changes  in  the  atmosphere.  A  sea  salt  bath  is  ben- 
eficial. 

Medicinal. — Cod  liver  oil,  in  these  cases,  is  of  great  benefit, 
and  it  can  be  used  either  plain  or  in  an  emulsion. 

The  oil  should  be  looked  upon  as  a  food  as  well  as  medicine, 


512  THE  DISEASES  OP   CHILDREN. 

and  its  effects  closely  watched.  If  it  is  regurgitated  or  if  it  is 
passed  unchanged  in  the  stools  the  dose  must  be  lessened  or 
it  should  be  temporarily  withdrawn.  If  used  plain  it  can  be 
given  in  gradually  increasing  doses,  until  the  maximum  dose  is 
reached,  from  5  drops  to  1  teaspoonful,  after  meals.  None  of 
the  so-called  extractives  of  cod  liver  oil  are  satisfactory. 

Owing  to  the  lime  needed  in  bony  formation,  the  combina- 
tions of  the  hyphophosphites  of  lime  with  the  emulsion  of  oil 
are  of  benefit. 

Considerable  discussion  has  been  indulged  in  by  the  pediat- 
rists  on  the  value  of  phosphorus  in  rickets.  In  my  experience 
it  has  been  of  unquestioned  benefit.  It  can  be  given  either  as 
the  officinal  oil  of  phosphorus,  with  olive  oil  or  cod  liver  oil,  in 
dose  of  1/200  to  1/100  grain,  three  times  a  day.  Thompson's 
solution  containing  1/20  grain  to  the  drachm  can  be  used  also. 

Iron  in  some  form  is  nearly  always  indicated  sooner  or  later 
to  combat  the  tendency  to  anemia,  and  can  be  given  in  the  form 
of  the  hypophosphite  (ferri  hypophosphis,  U.  S.),  1  to  2  grains, 
in  the  form  of  a  syrup ;  the  tincture  of  the  chloride  of  iron,  with 
glycerine;  or  diastiron  in  drachm  doses.  These  should  be  given 
after  eating. 

For  excessive  head  sweating  atropia  sulphate  in  1/800  grain 
doses  can  be  given  at  bed  time. 

Other  conditions  should  be  treated  as  they  arise,  pulmonary, 
dietetic  and  gastrointestinal  complications. 

Deformities  should  be  appropriately  handled.  Spinal  curva- 
tures by  decubitus;  tendency  to  bow-legs  or  knock-knee  by  keep- 
ing the  child  off  its  feet  and  off  the  floor.  Deformities  of  the 
pelvis  cannot  be  prevented  except  as  they  are  arrested  by  the 
general  improvement  from  appropriate  treatment  of  the  general 
underlying  condition.  Tendency  to  formation  of  spinal  curva- 
tures can  be  combated  by  recumbency  or  the  use  of  a  spinal 
frame  to  which  the  child  is  strapped  for  transporting. 


CHAPTER  XXII. 

DISEASES  OF  THE  NERVOUS  SYSTEM. 

GENERAL  CONSIDERATIONS. 

The  nervous  system  of  the  new-born  child  differs  from  the 
older  child  or  adult,  in  that  it  is  more  immature  in  develop- 
ment than  any  of  the  rest  of  its  tissues.  During  the  first  five  to 
seven  years  of  its  life  it  develops  more  rapidly  than  the  rest 
of  its  body,  especially  as  to  its  function.  Early,  the  brain  is 
unstable,  there  is  but  little  inhibition  of  nerve  force  or  energy, 
and  there  is  also  no  development  of  the  centers  controlling  the 
involuntary  muscles,  especially  the  sphincters.  The  nerve  cen- 
ters of  an  infant  or  child  react  to  reflex  stimulation  much  more 
readily  than  when  the  nervous  system  is  mature.  This  accounts 
for  the  frequency  of  convulsions  in  the  infant.  The  nervous 
system  of  the  child  is  more  susceptible  to  depressing  influences 
of  impoverished  blood  than  the  adults,  this  being  specially  true 
of  girls,  up  to  the  time  of  puberty  they  are  more  prone  to  de- 
velop serious  functional  and  organic  nervous  troubles. 

The  question  of  heredity,  so  little  understood,  is  one  to  be 
seriously  thought  of  in  the  diseases  of  the  nervous  system. 

Nervous  diseases  are  either  functional  or  organic.  Among 
the  former  are  chorea,  convulsions  of  reflex  origin,  neurasthenia, 
hysteria,  in  these  troubles  there  being  no  pathological  condition 
responsible  for  the  disease.  In  the  organic  form  there  are  path- 
ologic changes  in  the  cells  and  nerve  tissue. 

DIAGNOSTIC  METHODS. 

"With  a  nervous  disorder  suspected,  a  careful,  systematic  exam- 
ination must  be  made.  In  conditions  such  as  chorea  or  hysteria, 
if  the  child  can  be  watched  at  play,  or  while  recumbent,  entirely 
casually,  without  the  child's  attention  being  called  to  the  fact 
that  it  is  being  watched,  a  much  better  idea  of  the  symptoms 

513 


514  THE  DISEASES  OP   CHILDREN. 

can  be  had.     If  the  child  is  under  constraint  with  a  conscious- 
ness of  being  watched,  the  symptoms  will  be  modified. 

It  may  be  necessary  to  have  the  child  w'alk,  if  possible,  to 
learn  whether  there  are  any  paralyses,  the  character  of  the  gait, 
whether  there  is  a  spastic  condition  of  the  muscles  of  the  ex- 
tremities, atrophies  or  deformities.  The  child  should  be  made 
to  squeeze  one  or  two  fingers  of  the  examiner  to  obtain  the  con- 
tractile power  of  these  muscles,  to  hold  the  hand  out  straight, 
lightly  touching  the  open  palm  of  the  examiner  to  obtain  any 
fibrillary  twitchings  of  the  muscles.  The  examination  should 
not  be  concluded  without  the  child  is  stripped  and  all  parts  of 
its  body  examined,  especially  the  spine. 

The  reflexes  must  be  tested,  the  most  important  being  the  fol- 
lowing : 

The  Knee  Jerk. — In  the  very  young  this  is  difficult  to  ob- 
tain, in  older  children  it  can  be  elicited.  The  legs  are  allowed 
to  hang  over  the  edge  of  chair  or  table  and  the  patellar  tendon 
struck  gently  with  the  end  of  the  finger,  or  percussion  hammer, 
as  in  percussion  of  the  chest.  The  child's  attention  is  diverted 
during  this  manipulation  by  having  it  clench  its  hands  tightly 
together  and  pull  hard. 

The  Biceps  Jerk. — The  child's  arm  is  held  flexed  and  relaxed 
with  the  thumb  of  the  hand  supporting  the  arm,  held  along  the 
biceps.  With  the  second  finger  or  with  a  percussion  hammer 
the  biceps  is  struck  a  gentle  blow  direct,  or  the  thumb  is  per- 
cussed and  the  muscle  can  be  felt  to  contract. 

Crema.steric  Reflex. — By  stroking  the  inner  aspect  of  the 
thigh  with  the  finger  the  muscle  of  the  scrotum  contracts,  rais- 
ing the  testicles. 

Sensation. — The  examination  for  sensation  should  include  the 
examination  for  the  presence  or  absence  of  sensation  of  pain  and 
the  period  of  time  which  elapses  before  the  sensation  is  received. 
A  pin,  camel-hair  brush,  hot  and  cold  substances,  are  needed 
to  elicit  this  symptom.  The  child's  expression  should  be  closely 
watched  for  the  evidence  of  the  reception  of  sensory  impres- 
sions. This  symptom  is  of  importance  in  spinal  cord  lesions. 
The  fontanelles  should  be  examined  and  note  made  if  they  are 
open,  sunken  or  bulging  and  tense. 


DISEASES   OF   THE   NERVOUS   SYSTEM.  515 

Babinski's  Reflex. — Irritation  of  the  soles  of  the  feet  causes 
a  dorsi-flexion  of  the  great  toe  toward  the  dorsum  of  the  foot, 
while  the  other  four  toes  are  flexed  toward  the  sole  of  the  foot. 

Kemig's  Sign. — In  1882  Kernig  described  a  condition  which 
is  more  or  less  pathognomonic  of  meningitis.  It  consists  in 
the  inability  to  extend  the  leg  fully  on  the  thigh,  the  thigh  being 
flexed  at  a  right  angle  with  the  trunk.  It  is  involuntary  and  is 
not  accompanied  by  or  due  to  pain.  Kernig  considers  the  sign 
positive  when  the  angle  is  135° ;  others  place  it  at  120°  or  even 
115°. 

Morse  concludes  it  is  almost  never  found  in  infancy,  either 
in  health  or  disease,  except  in  meningitis.  It  occurs  with  equal 
frequency  at  all  stages  of  .the  disease.  It  is  of  no  importance 
as  a  diagnostic  sign  between  the  tuberculous  and  cerebrospinal 
forms. 

The  vision  of  the  child  should  be  tested.  The  mother  is 
often  deceived  as  to  this  point.  A  lighted  taper  or  bright  ob- 
ject moved  in  front  of  the  eyes  will  cause  them  to  follow  the 
object  back  and  forth.  The  pupils  are  examined  to  ascertain 
if  they  are  equal,  and  if  they  contract  promptly  to  light  stimu- 
lation. Constant  movement  of  the  eye,  nystagmus,  is  a  very 
striking  symptom. 

The  hearing  should  be  carefully  tested  by  a  sudden  sound,  as 
a  whistle,  or  clapping  the  hands,  being  made  behind  the  child. 

Squire's  Sign. — The  child  lying  on  its  back,  the  head  is 
grasped  and  slowly  extended  as  far  as  possible.  The  pupils 
dilate  during  this  and  contract  as  the  head  is  flexed. 

Electrical  Examinations. — As  an  aid  to  diagnosis  electricity 
is  of  great  value.  The  nerves  of  the  new-born  respond  only  to 
strong  currents.     Children  are  easily  frightened  by  this  test. 

The  examination  is  begun  wdth  the  faradic  current,  one  pole 
on  the  muscle  to  be  examined,  the  other  on  the  chest,  and  only 
a  current  strong  enough  to  produce  a  contraction  is  used.  In 
inflammatory  and  degenerative  conditions  of  the  nerves,  both  the 
nerves  and  muscles  show^  a  diminution  in  the  faradic  response, 
but  the  muscles  may  continue  to  partially  respond  to  the  gal- 
vanic current,  and  these  changes  are  called  the  reaction  of  de- 
generation. 


516  THE   DISEASES   OF    CHILDREN. 

Electricity  is  also  of  value  in  differentiating  cerebral  disease 
and  diseases  of  the  spinal  cord  and  peripheral  nerves. 

Lumbar  Puncture. — As  a  method  of  diagnosis  this  procedure 
is  of  value,  and  is  performed  as  follows :  The  child  can  lie  upon 
its  side,  with  head  and  shoulders  elevated,  and  slightly  bent 
forward,  putting  the  tissues  of  the  back  on  a  stretch.  The  latter 
position  favors  the  flow  of  fluid.  The  skin  is  thoroughly  ster- 
ilized with  soap  and  water  and  alcohol.  A  general  anesthetic 
can  be  administered  if  desired,  or  local  anesthesia  with  cocaine, 
Schleich's  solution  or  kelene. 

The  puncture  is  made  with  an  ordinary  aspirating  platinum- 
needle  or  small  trocar,  9  or  10  cm.  long,  and  1  mm.  in  diameter, 
which  is  sterilized  by  boiling  10  minutes.  The  puncture  does 
not  hurt  much  more  than  the  introduction  of  the  cocaine. 

The  space  between  the  third  and  fourth,  or  fourth  and  fifth, 
lumbar  vertebrae  is  selected,  as  at  this  point  the  cord  is  not 
injured.  The  iliac  crests  are  on  a  level  with  the  fourth  spinous 
process,  and  the  needle  with  one  motion  plunged  to  the  inter- 
vertebral cartilage  1  em.  to  one  side  of  the  median  line.  If  the 
cartilage  is  located  with  certainty  the  canal  is  entered  with  the 
point  of  the  needle,  and  to  a  depth  of  about  3  or  4  cm.  The 
cerebrospinal  fluid  at  once  escapes,  at  the  rate  of  1  or  2  drops 
a  second,  or  even  slower  in  some  cases.  To  make  a  thorough 
examination  of  the  fluid  4  cc.  to  5  cc.  should  be  obtained,  and 
should  be  dropped  directly  into  the  capillary  tube  of  the  centri- 
fuge, after  obtaining  enough  for  cover-slip  examination. 

The  normal  cerebrospinal  fluid  is  clear,  and  of  a  gravity  of 
1003,  and  contains  a  trace  of  albumin  and  is  practically  free 
from  cells.  In  inflammation  of  the  meninges  the  fluid  is  cloudy 
from  an  exudation  of  cells,  dependent  of  course  upon  the  char- 
acter of  the  exudate.  In  the  tubercular  form  there  is  very 
little  cellular  exudate. 

Cover-glass  preparations  (from  the  fresh  fluid  as  it  is  with- 
drawn or  from  the  sediment  in  the  capillary  tube,  the  latter 
preferable)  are  stained  with  Wright's  stain.  Tothe's  method 
of  diagnosis  has  been  given. 

In  tuherciila?'  meningitis  the  fluid  appears  clear,  as  a  rule,  ex- 
cept  on  close   examination.     If   the  test   tube   containing   the 


DISEASES   OP   THE   NERVOUS   SYSTEM. 


517 


Fig.    83. — Locating    the    intcr-vtiti'ljiiil    space    for    lumbar    puncture.      Middle    fingers 
on   crest  of  ilium,   index  finger  one-half  inch  above  this  line. 


Fig.   84. — Lumbar  puncture.     Nurse  holding  sterile  bottle  to  catch   fluid. 


518  THE   DISEASES   OP    CHILDREN. 

fluid  is  allowed  to  stand  upright  in  an  ice  box  for  24  hours  a 
precipitate  or  coagulura,  wedge  or  funnel-shaped  forms,  which 
is  fairly  characteristic  of  this  type. 

If  many  polynuclear  leucocytes  are  found  in  the  sediment 
it  is  not  the  tubercular  form.  The  large  and  small  lymphocytes 
in  the  sediment  indicate  tubercular  meningitis.  The  inocula- 
tion of  guinea-pigs  may  be  necessary  to  clear  up  the  diagnosis 
of  the  tubercular  form. 

In  the  suppurative  form  of  meningitis  the  fluid  is  very  cloudy 
and  contains  pus  cells,  and  a  large  number  of  leucocytes. 

In  epidemic  cerebrospinal  meningitis  the  same  procedures 
are  gone  through  with  and  the  sediment  examined  for  the  diplo- 
coccus  intracellularis. 

FUNCTIONAL  DISEASES  OF  THE  NERVOUS  SYSTEM. 

CONVULSIONS. 

Infantile  Eclampsia. 

This  is  a  symptom  and  not  a  disease,  and  consists  in  a  motor 
discharge,  resulting  from  a  cerebral  irritation,  evidenced  by  con- 
clusive movements  or  contractures  of  the  muscles  of  one  or  more 
parts  of  the  body. 

Etiology. — The  nervous  system  of  the  child  is  so  subject  to 
reflex  stimuli,  and  the  inhibitory  power  of  the  brain  is  so 
poorly  developed,  that  convulsions  occur  with  comparative  fre- 
quency. Among  these  stimuli  are  the  toxins  generated  at  the 
onset  or  during  the  exanthemata,  toxins  generated  in  the  gas- 
trointestinal tract,  rachitis,  phimosis,  dentition  and  a  host  of 
other  conditions  may,  reflexly,  cause  convulsions.  When  oc- 
curring during  the  first  week  or  two  of  life  the  convulsion  may 
be  due  to  pressure  on  the  brain  from  within,  from  a  hemor- 
rhage; later  to  an  organic  disease  of  the  brain,  as  an  abscess, 
hemorrhage,  meningitis,  etc. ;  they  may  be  due  to  an  hereditary 
condition,  epilepsy,  or  may  be  traumatic.  Convulsions  are  much 
more  frequent  during  the  first  two  years  of  life. 

Symptoms. — The  convulsions  may  be  the  first  evidence  of 
trouble,  or  it  may  present  many  preliminarj-  symptoms.  No 
two  are  alike,  yet  there  are  certain  symptoms  common  to  most. 


DISEASES   OF   THE   NERVOUS   SYSTEM.  519 

The  seizure  is  usually  ushered  in  by  a  preliminary  cry,  the 
muscles  of  the  face  contract  and  the  child  at  once  develops  tonic 
and  then  clonic  convulsions  of  one  or  more  parts  or  of  the  entire 
body.  The  head  is  thrown  backward,  and  the  back  may  be 
arched,  the  weight  of  the  body  supported  by  the  back  of  the  head 
and  the  heels,  the  position  of  opisthotonos.  The  eyes  are 
rolled  upward,  and  the  pupils  are  dilated  and  fixed;  there  is  a 
snoring  respiration,  spasmodic  in  character,  due  to  the  contrac- 
tions of  the  diaphragm,  and  the  face  becomes  a  dusky  color. 
If  the  convulsion  lasts  some  time,  deep  asphyxia  may  be  present. 
The  tongue  may  be  bitten  in  older  children  if  protruded  be- 
tween the  teeth.  Clonic  or  slight  convulsions  follow  the  tetanic 
ones,  and  when  quiet  the  child  falls  into  a  sleep  or  a  state  of 
coma,  to  waken  rational  or  to  go  without  regaining  conscious- 
ness into  another  more  or  less  severe  spasm.  The  urine  and 
feces  may  be  passed  involuntarily. 

Prognosis. — A  single  convulsion  may  give  rise  to  no  sequelae, 
but  repeated  ones  are  serious,  as  they  may  be  the  starting  point 
of  severe  organic  lesion  of  the  brain,  resulting  in  epilepsy.  The 
prognosis  depends  very  largely  upon  the  cause  of  the  condition. 
If  due  to  the  exanthemata  there  may  be  no  recurrence,  as  early 
elimination  removes  the  disturbing  element. 

Treatment. — The  convulsive  seizure  must  be  controlled,  and 
this  can  probably  best  be  done  by  the  inhalation  of  chloroform. 
The  first  thought  of  the  mother  and  laity  is  to  place  the  child 
in  hot  water,  and  much  harm  has  undoubtedly  been  done  by 
this  procedure.  The  child  is  exposed  unduly,  and  frequently 
burned,  by  too  hot  water  being  used,  in  the  excitement.  Ju- 
diciously applied  the  relaxing  effect  of  a  plain  full  bath  or  of  a 
mustard  bath  may  be  very  pronounced. 

The  next  indication  is  to  remove  the  cause  if  possible.  Be- 
cause of  the  frequency  of  toxins  from  the  intestine  being  the 
cause,  as  soon  as  the  child  can  swallow,  a  dose  of  castor  oil  should 
be  administered  to  completely  empty  the  intestinal  canal.  A 
colon  irrigation  should  be  given  early.  This  may  be  cool  if  there 
is  much  fever.  Rest  and  quiet  are  most  essential.  To  prevent 
a  recurrence  the  child  is  given  one  of  the  bromides,  along  or 
with  chloral  hydrate  (bromide  of  strontium,  gr.  v,  with  chloral, 


520  THE  DISEASES   OP    CHILDREN. 

gr.  iv),  over  a  period  of  several  days  or  a  week  or  more.  If 
unable  to  swallow  the  first  dose  may  be  given  by  the  rectum 
following  the  irrigation  and  emptying  of  the  bowel.  The  gen- 
eral treatment  of  the  underlying  physical  condition  is  important. 
If  there  is  rachitis  it  must  be  given  appropriate  treatment,  and 
child  kept  closely  under  observation.  If  of  school  age,  it  should 
be  kept  away  from  school  for  an  indefinite  time. 

CHOREA. 

Varieties. — Several  varieties  of  this  disease  are  recognized 
under  the  generic  term  of  choreiform  diseases,  the  variety,  how- 
ever, usually  indicated  by  the  unqualified  term  chorea,  is  chorea 
minor,  or  acute  chorea. 

The  other  varieties  are  chorea  major,  Huntington's  or  hered- 
itary chorea,  hahit  chorea,  electric  chorea. 

CHOREA  MINOR. 

Synonyms. — St.  Vitus'  dance;  Sydenham's  chorea;  acute 
chorea. 

Definition. — A  neurosis,  occurring  almost  exclusively  in  chil- 
dren before  puberty,  characterized  by  involuntary  movements 
and  twitchings  of  muscles  or  groups  of  muscles  of  the  body. 

Etiology. — There  is  unquestionably  a  close  relationship  be- 
tween this  disease,  rheumatism  and  tonsillitis.  Among  the 
other  diseases  which  bear  a  causal  relationship  are  the  exanthe- 
mata, tonsillitis,  diphtheria.  There  may  not  be  a  distinct  his- 
tory of  rheumatism,  but  of  vague  pains  in  the  joints,  which 
without  close  questioning  would  probably  not  be  mentioned  in 
the  history.  The  occurrence  of  heart  lesions  in  chorea,  reported 
by  many  observers,  is  a  further  confirmation  of  this  theory. 

The  majority  of  cases  occur  between  the  ages  of  10  and  15 
years.  Girls,  about  the  age  of  puberty,  are  more  prone  to  de- 
velop it.  Unhygienic  surroundings  with  poor  food,  which  leads 
to  intestinal  intoxication,  are  predisposing  causes  frequently 
seen.  Crowding  at  school,  both  as  to  the  number  in  the  classes 
and  the  amount  of  work  accomplished,  may  act  as  causes.  He- 
redity is  also  a  factor.  Either  direct  history  of  chorea  in  the 
mother  or  a  mother  of  an  excessively  nervous  temperament  may  . 


DISEASES   OF   THE   NERVOUS   SYSTEM.  521 

be  elicited.  Dr.  Weir  Mitchell  has  claimed  that  a  larger  num- 
ber of  cases  occur  in  the  spring  of  the  year.  A  sudden  shock 
to  the  child,  as  a  severe  fright,  may  induce  an  attack. 

Pathology. — No  characteristic  or  constant  change  has  been 
found  in  the  nervous  system  in  those  cases  which  have  been  exam- 
ined at  autopsy.  Among  the  changes  reported  by  different 
observers  are  the  following,  vascular  changes,  as  the  result  of 
an  infection;  cortical  changes  of  an  indefinite  kind,  chiefly  a 
calcification  of  the  ganglion  cells  (Golgi) ;  connective  tissue  in 
the  spinal  cord  and  nerve  centers  (Garrod)  ;  calcification  of 
ganglion  cells  (Golgi)  ;  hyperemia  of  the  brain  and  cord,  and 
simple  changes  in  the  serous  membranes.  Tonsillitis  and  endo- 
carditis may  be  found. 

Symptoms. — In  the  mild  form  of  chorea  there  may  be  few 
or  no  prodromal  symptoms,  perhaps  a  short  period  of  irritability 
or  depression,  in  which  the  child  cries  easily  and  without  provo- 
cation, followed  shortly  by  a  contraction  or  twitching  of  a  group 
of  muscles.  This  may  evidence  itself  by  a  spasmodic  winking  of 
the  eyes  or  jerking  of  the  facial  muscles,  usually  of  one  side  or  a 
jerking  or  raising  of  the  arm  or  shoulder.  The  muscles  of  the 
hands  soon  become  involved  and  the  child  drops  articles  with- 
out cause,  it  appears  awkward  at  the  table  and  handles 
eating  utensils  clumsily.  If  the  lower  extremities  are  involved 
it  may  walk  jerkily,  a  peculiar  gait,  which  is  almost  indescrib- 
able. The  tongue  is  affected,  even  in  the  mildest  form,  and  the 
speech  may  be  halting  or  stammering  and  thick.  This  is  espe- 
cially true  if  the  muscles  of  the  larynx  are  involved. 

The  choreic  movements  usually  cease  entirely  during  sleep, 
and  may  do  so  even  in  the  severe  forms. 

Relapses  are  very  common.  These  may  occur  in  a  short  time 
or  a  year  or  more  may  elapse  between  attacks.  The  duration  is 
very  variable,  from  a  few  weeks  to  several  months,  depending 
largely  upon  the  time  at  which  treatment  is  begun. 

Severe  Chorea.- — This  form  is  essentially  like  the  mild,  except 
in  the  extent  of  muscular  involvement  and  the  severity  of  the 
twitchings  and  contractions. 

One  case  under  my  observation  was  admitted  to  the  female  ward  of  the 
City  Hospital  during  my  service.     She  was  a  girl  13  years  of  age,  with  a 


522  THE   DISEASES   OP    CHILDREN, 

history  of  severe  chorea  for  about  a  month.  She  had  severe,  general  con- 
vulsive movements,  with  traumatic  bed  sores  upon  the  heels,  hips,  elbows 
and  shoulder  blades.  Until  the  contractions  could  be  controlled  it  was 
necessary  to  put  padded  sides  to  the  bed  to  keep  her  from  falling  upon 
the  floor.     Mild  twitchings  were  present  during  sleep. 

Diagnosis. — Posthemiplegic  Chorea. — Choreiform  movements 
may  follow  the  cerebral  palsies  of  infancy.  They  are  usually 
of  one  extremity.  Contractures  occur  as  a  rule  in  this  form, 
followed  by  paralysis  of  the  part.  Epilepsy,  hysteria,  habit 
chorea,  must  be  borne  in  mind  and  eliminated  by  exclusion. 

Pericarditis  may  occur,  but  is  rarely  seen. 

Treatment. — The  first  indication  is  to  put  the  child  to  bed 
and  at  a  complete  rest,  without  a  pillow,  and  with  no  book  or 
other  form  of  amusement.  These  patients  invariably  do  better 
if  removed  from  home,  mother  and  friends,  or  if  this  is  not 
possible  put  to  bed  at  home,  and  in  charge  of  a  competent 
trained  nurse,  with  family  and  friends  excluded.  This  is  very 
often  difficult  of  accomplishment,  and  will  be  looked  upon  as  in- 
human and  cruel  by  the  average  mother,  but  by  firmness,  yet 
with  tact,  it  can  usually  be  done. 

This  complete  rest  and  isolation  does  more  toward  obtaining 
a  cure  than  any  other  form  of  treatment,  medical  or  otherwise. 
Some,  and  very  often  all,  of  the  opposition  to  this  rest  may  come 
from  the  patient,  but  it  is  usually  overcome  in  a  few  days. 

The  diet  should  be  simple,  regular  and  nutritious.  Milk 
should,  perhaps,  be  the  basis  of  the  diet,  with  later,  eggs,  farin- 
aceous food  and  vegetables. 

Gentle  rubbing  or  massage  following  a  daily  warm  bath  is 
a  valuable  adjuvant  in  treatment.  In  some  cases  the  galvanic 
current  is  of  benefit.     Bran  and  salt  baths  are  of  assistance. 

Medicinally,  no  one  remedy  offers  the  same  advantages  as  ar- 
senic. A  useful  form  is  Fowler's  solution,  and  it  should  be 
given  in  very  gradually  increasing  doses.  Begin  with  1  to  3 
drops  after  meals  and  increase  1  drop  a  day  at  first  then  in- 
crease 1  drop  each  dose.  If  given  in  this  Avay  it  can  be  increased 
to  a  much  larger  dose  before  physiologic  effects  are  noted. 

Physiologic  effects  may  show,  as  a  puffing  of  the  eyelids, 
usually  the  lower,  or  gastric  and  abdominal  pain,  cramping  in 
character.     Both  syiui)toms  may  not  be  present  in  every  case. 


DISEASES   OF   THE   NERVOUS   SYSTEM.  523 

In  the  case  of  the  severe  form  referred  to,  the  maximum  dose  reached, 
was  1  teaspoonful.  It  was  then  decreased  in  amount  to  20  drops  at  the 
same  ratio  as  increased  (1  drop  each  dose),  at  which  time  she  was  prac- 
tically well,  was  up  and  walking  about  the  yard. 

In  one  case,  a  boy  of  nine  years,  an  inmate  of  an  institution  under  treat- 
ment for  his  second  attack  of  chorea,  the  arsenic  was  continued  in  in- 
creasing doses  until  20  drops  was  reached  before  physiologic  symptoms 
were  noted.  Instead  of  decreasing  at  this  time,  as  customary,  the  maxi- 
mum dose  was  continued  after  the  boy  was  dismissed  from  the  institution 
infirmary.  After  taking  the  maximum  dose  for  three  weeks  it  was  noticed 
he  could  not  keep  up  in  the  school  line  because  of  a  shuffling  and  hesitating 
gait.  He  was  seen  a  few  days  later  and  a  neuritis  of  both  lower  extremi- 
ties found.  This  was  evidenced  by  delayed  sensation  of  the  foot,  partial 
paralysis  of  the  legs,  and  the  reaction  of  degeneration  of  the  muscles  be- 
low the  knees  under  static  electricity.  After  discontinuance  of  the  ar- 
senic he  has  greatly  improved,  but  at  the  end  of  three  months  is  still  quite 
lame. 

Symptomatic  treatment  in  all  eases  is  indicated.  Attention 
to  the  bowels  is  very  necessary.  Nightly  doses  of  aromatic 
cascara  are  usually  of  great  benefit.     Enemata  may  be  indicated. 

In  the  severe  forms,  in  which  there  is  a  great  muscular  move- 
ment, the  child  must  be  controlled  by  the  hypodermic  admin- 
istration of  morphia,  the  dose  appropriate  to  the  age. 

The  temperature  should  not  be  taken  in  the  mouth  from  dan- 
ger of  the  thermometer  being  broken. 

The  child  should  be  kept  from  school  for  several  months 
after  apparent  restoration  of  health. 

HEREDITARY  CHOREA. 

Synonyms. — Huntington's  chorea;  chronic  chorea. 

Etiology. — This  form  of  chorea  is  rare.  There  is  always  a 
distinct  history  of  heredity  perhaps  in  one  or  two  generations. 
It  is  not  a  disease  of  childhood,  occurring  usually  after  the  age 
of  20.  It  may  affect  one  or  more  in  the  same  family,  but  may 
develop  in  a  young  child  of  a  sufferer  from  this  form. 

Symptoms.— It  is  a  disease  of  adult  life,  most  cases  occurring 
between  20  and  30  years  of  age.  It  is  much  like  chorea  minor, 
only  the  contractions  are  more  severe,  affecting  chiefly  the 
muscles  of  the  face,  peculiar  grimaces  being  made,  and  of  the 
arm  and  upper  trunk.     Sooner  or  later  a  mental  condition  de- 


524  THE   DISEASES   OF    CHILDREN. 

velops,  which  is  much  like  dementia,  following  a  short  period 
of  irritability  and  apathy. 

Prognosis. — This  is  grave  as  to  recovery.  They  may  live 
years. 

Treatment. — No  treatment  is  of  avail,  the  only  recourse  be- 
ing confinement  in  an  asylum  or  institution  for  the  insane  or 
feeble-minded.     Symptomatic  treatment  is  of  course  indicated. 

HABIT  CHOREA. 

Synonym. — Cmivulsive  tic. 

Symptoms. — This  form  of  chorea  occurs  in  the  delicate  and 
cachetic  children,  chiefly  in  those  children  who  can  best  be  de- 
scribed as  "spoiled."  The  only  manifestation  may  be  a  t\\atch- 
ing  of  a  muscle  of  the  face,  contraction  of  one  or  both 
eyelids,  raising  the  eyebrow,  drawing  down  of  a  corner  of  the 
mouth,  pulling  down  or  up  of  one  shoulder,  contraction  of  the 
sternocleidomastoid  muscle,  pulling  the  head  down  and  out, 
supinating  or  pronating  the  forearms,  protruding  the  tongue, 
twitching  of  the  fingers,  etc.  A  starting  point  of  this  may  be  a 
binding  of  one  of  the  articles  of  clothing,  the  shoulder  for  in- 
stance, being  raised  to  relieve  it  of  pressure. 

Diagnosis. — This  is  not  always  easily  made  from  a  mild 
chorea,  except  by  the  oft-repeated  contractions  of  the  same  mus- 
cle or  group  of  muscles,  a  purposeful  movement. 

Peterson  describes  a  condition  which  he  calls  gyrospasms  of 
the  head,  the  head  being  rotated  to  the  right  or  left  many  times 
per  minute  and  often  accompanied  by  nystagmus.  In  these 
cases  he  found  a  history  of  rickets  or  intestinal  irritation. 

Treatment. — The  cause  may  be  reflex  and  should  be  searched 
for,  eye  strain,  phimosis,  abnormalities  of  the  ears  and  teeth, 
tight  clothing,  irritating  underclothes,  may  be  a  cause,  and  if 
present,  removed. 

The  diet  should  be  controlled,  sweets  entirely  eliminated,  and 
regular  meals  insisted  upon.  No  tea  or  coffee  should  be  allowed. 
Removal  from  school  until  relieved.  Proper  rest  and  regular 
hours  for  sleep.  Daily  warm  baths  followed  by  a  cool  sponge 
if  possible,  and  a  vigorous  rub.  Suggestion  is  of  value  in  some 
cases. 


DISEASES   OF   THE   NERVOUS    SYSTEM.  525 

Medicinally,  arsenic  is  of  value,  alone  or  best  in  combination 
with  the  bromides.     General  tonics  are  indicated  very  often. 

ELECTRIC  CHOREA. 

This  is  a  rare  disease,  so  named  because  of  the  rapidity  with 
which  the  movements  follow  one  upon  the  other.  They  are 
violent  as  a  rule.     Dubini  first  described  the  condition  in  1846. 

The  muscles  of  the  neck  and  face  are  principally  affected, 
but  the  arms  and  legs  may  also  be  involved.  After  varying 
duration  of  the  active  choreiform  condition,  the  cases  are  de- 
scribed as  developing  atrophy  and  paralyses  in  the  affected 
muscles  or  group  of  muscles,  with  perhaps  complete  paralysis. 
There  may  be  pain  and  an  elevation  of  temperature,  the  symp- 
toms, collectively,  and  the  termination  suggesting  a  severe  in- 
toxication. 

HYSTERIA. 

This  is  a  comparatively  rare  condition  in  childhood,  but  occa- 
sionally seen  about  puberty  or  following  this  period. 

Etiology. — A  "neurotic"  family  history  is  usually  present, 
and  it  occurs  in  the  "spoiled"  child,  more  often  in  girls.  Over- 
crowding at  school  is  a  potent  factor,  fright,  emotional  and  sen- 
sational plays  and  books  may  influence  it.  There  is  usually  a 
history  of,  the  child  being  delicate,  perhaps  having  had  the  ex- 
anthemata and  other  illnesses,  a  variable  appetite,  with  frequent 
digestive  disturbances. 

Symptoms. — These  are  usually  divided  into  groups,  accord- 
ing to  the  various  systems  involved,  sensory,  motor,  mental  or 
psychic. 

Sensory  Manifestations.— These  symptoms  may  be  mani- 
fested by  hyperesthesia  or  anesthesia.  The  severity  of  the  pain 
complained  of  is  at  once  suggestive  of  the  diagnosis.  The  slight- 
est touch  or  even  if  the  patient  thinks  it  will  be  touched  causes 
severe  complaint.  The  location  of  the  pain  or  point  of  tender- 
ness does  not  correspond  to  the  distribution  of  the  nerve  supply- 
ing the  part.  Anesthesia,  if  present,  usually  involves  half  the 
body,  and  of  itself  is  a  suggestive  occurrence.  Anesthesia  of 
one  area  or  region  may  also  be  present. 

Photophobia  may  be  present,  or  complete  loss  of  sight  in  one 


526  THE   DISEASES   OF    CHILDREN. 

eye  or  loss  of  vision  to  part  of  the  eye.  The  visceral  form  of 
hysteria  may  be  mentioned  here.  The  patient  may  refuse  food 
entirely,  or  if  taken  may  shortly  be  followed  by  contraction  of 
the  stomach  and  vomiting  without  nausea.  There  may  be  diar- 
rhea in  this  form  also.  Tympanites  is  often  present.  Hyster- 
ical hiccough  is  encountered,  and  an  inability  to  swallow. 
Globus  hystericus,  stricture  of  esophagus  is  not  present.  Nau- 
sea and  vomiting  may  occur. 

Motor  Manifestations. — ^These  are  evidenced  by  a  variety  of 
convulsive  movements  w^hich  may  affect  the  entire  body  or 
groups  of  muscles,  one  or  both  arms,  or  both  legs,  etc.  Sensory 
symptoms  may  be  present  also.  The  following  case  is  illus- 
trative of  this  type  of  hysteria : 

A  11-year-old  girl  was  seen  in  consultation,  who  for  three  months  had 
had  severe  "convulsions,"  occurring  principally  in  the  forenoon.  The 
mother  was  thin,  anemic,  subject  of  organic  heart  disease,  and  very 
"nervous."  When  shown  into  the  child's  room  the  mother  said,  after  we 
had  talked  for  a  few  moments:  "Have  one  of  your  spells  now,  you've  had 
them  this  morning."  Very  shortly  the  child  began  with  convulsive,  up-and- 
down  movements  of  arms  and  forearms,  tightly  clenched  its  hands  to- 
gether, moved  up  and  down  in  bed,  gave  two  or  three  long-drawn  inspira- 
tions with  its  mouth  tightly  contracted  and  then  relaxed,  smiling  shortly 
after.     The  knee  reflexes  were  exaggerated. 

Hiccough  is  a  frequent  form  of  muscular  contraction.  Hys- 
terical aphonia  is  a  common  condition  in  hysteria,  esophageal 
spasm  being  often  associated. 

Mental  or  Psychic. — Usually  with  either  of  the  other  group 
of  symptoms  there  is  a  decided  perverted  mental  condition,  the 
child  being  extremely  emotional.  The  phenomenon  usually 
called  hysteria  is  frequent,  uncontrollable  laughter  followed  by 
crying,  or  vice  versa.  Sachs  terms  an  exaggeration  of  this  con- 
dition hysterical  mania,  the  child  trying  to  do  itself  or  others 
violence,  being  in  a  frenzy.  Sympathy  may  precipitate  such 
an  attack. 

Diagnosis. — If  the  motor  symptoms  are  pronounced  the 
trouble  may  have  to  be  diagnosed  from  epilepsy.  The  child  is 
in  a  condition  of  hysteroepilepsy.  In  this  form  of  convulsive 
attack  there  is  no  aura,   the  onset  is  gradual,  there  may  be 


DISEASES  OP  THE   NERVOUS   SYSTEM.  527 

noises  made  throughout  the  attack,  there  is  no  impairment  of 
vesical  and  rectal  reflexes;  the  attacks  last  much  longer,  fol- 
lowed usually  by  a  condition  of  trance;  biting  of  the  tongue  is 
rare. 

Treatment. — As  in  chorea,  only  the  indication  is  even  more 
pronounced,  the  first  thing  to  be  accomplished  is  to  isolate  the 
child  from  family  and  friends.  This  is  far  easier  and  better 
done  by  removing  the  child  to  an  institution  for  the  sick,  and 
isolate  it  with  a  special  nurse.  The  choice  of  a  nurse  is  very 
essential.  She  should  be  firm,  yet  kind,  and  the  child  made  to 
understand  from  the  beginning  that  the  nurse  is  in  authority 
in  the  absence  of  the  physician  and  absolutely  in  control.  As 
soon  as  the  acute  symptoms  are  corrected  the  child  should  be 
placed  under  the  care  of  a  competent  nurse  or  governess  at  home, 
and  the  same  strict  regime  carried  out  there.  What  teaching  is 
done,  must  be  at  home  and  not  at  a  general  or  private  school. 
Later  private  schools  are  of  benefit,  with  limited  number  of  pu- 
pils where  individual  attention  can  be  given. 

Careful  written  directions  must  be  given  in  regard  to  the 
whole  life  and  routine  of  the  patient,  diet,  dress,  habits,  cloth- 
ing, exercise  and  play. 

Suggestive  therapeutics  in  these  cases  are  of  the  very  greatest 
help,  and  should  be  carefully  and  conscientiously  employed. 
Electricity  may  be  classed  under  this  head. 

In  some  cases,  in  older  children,  especially  where  hysterical 
paralyses  and  joints  are  encountered,  blisters  and  the  actual 
cautery  are  of  the  most  signal  benefit.  It  may  not  be  necessary 
to  use  them,  their  exhibition  and  explanation  of  method  of 
procedure  is  usually  all  that  is  needed  for  a  complete  ''cure." 
Cold  douches  to  the  back  are  also  efficacious. 

In  the  anorexia  and  vomiting,  stomach  washing  and  nasal 
feeding  through  tube,  or  gavage,  usually  brings  prompt  and 
favorable  results. 

EPILEPSY. 

A  functional  disorder  of  the  nervous  system  characterized  by 
tonic  and  clonic  convulsions  at  intervals,  of  the  entire  or  a  por- 
tion of  the  muscular  system  of  the  body,  and  attended  by  loss 
of  consciousness. 


528  THE   DISEASES   OF    CHILDREN. 

Etiology. — There  is  no  distinct  etiology  which  is  present  in 
all  cases.  Heredity  plays  an  important  role  in  the  etiology, 
a  history  of  epilepsy,  insanity  or  severe  nervous  disease  in  the 
family  being  present  in  a  majority  of  cases.  Consanguinity, 
alcoholism,  syphilis,  trauma  are  given  as  causes.  Infantile  cer- 
ebral hemorrhages  are  also  a  cause.  Females  are  more  often 
affected.  The  majority  of  cases  occur  between  5  and  15  years 
of  age.  Many  reflex  irritations  are  capable  of  precipitating 
the  attacks,  as  phimosis,  dental  irritation,  intestinal  inflamma- 
tions, visual  defects,  toxemias  and  intestinal  parasites.  i\Ias- 
turbation  is  also  a  cause.  Frequent  convulsions  from  reflex 
causes  may  eventuate  in  epilepsy. 

Pathology. — ^But  little  which  is  definite  is  known  of  the 
pathology  of  this  trouble,  except  in  those  cases  due  to  cerebral 
hemorrhages.  Degenerative  changes  have  been  found  in  the 
ganglion  cells,  with  hyperplasia  of  neuroglia  tissues.  Dana  gives 
the  chief  change  as  an  induration  or  sclerosis. 

Symptoms. — Two  types  are  generally  considered,  petit  trial 
and  grand  mal. 

Petit  Mal. — In  this  form  of  epilepsy  there  may  be  no  con- 
vulsions but  a  temporary  loss  of  consciousness  which,  because 
of  the  pallor  present,  may  be  diagnosed  as  a  fainting  attack. 

The  frequent  occurrence  of  this  phenomenon  should  arouse 
suspicion  at  once.  The  child  may  be  at  play  and  suddenly  stop, 
and  will  sit,  perhaps  fall  down;  its  face  will  become  pale,  eyes 
staring,  pupils  dilated  and  unconsciousness  will  follow  for  a 
brief  or  a  much  longer  period.  The  respiration  may  be  snoring 
in  character.  When  consciousness  returns  the  child  will  have  a 
dazed  expression  and  will  not  be  able  to  recognize  its  surround- 
ings. Usually  there  is  no  distinct  aura,  save,  perhaps,  a  vague 
uneasiness  felt  by  the  patient,  no  preliminary  cry  and  no  in- 
voluntary passage  of  urine  or  feces. 

Grand  Mal. — In  this  form,  which  is  usually  meant  when  the 
term  epilepsy  is  used,  several  distinct  stages  are  present,  (1) 
aura,  (2)  cry,  (3)  tonic  convulsions,  (4)  clonic  convulsions, 
(5)   unconsciousness. 

1.  Aura  or  Preliminary  Symptoms. — ^Premonitory  symptoms 


DISEASES   OF   THE   NERVOUS   SYSTEM.  529 

may  be  felt  by  the  patient  for  a  number  of  hours  before  the 
active  convulsive  stage  sets  in.  This  may  be  only  a  feeling  of 
giddiness,  numbness,  tingling,  vague  abdominal  sensations,  ex- 
citement or  depression,  aural  or  auditory  symptoms.  These 
warnings,  if  present  always  in  the  same  form,  enable  the  pa- 
tients to  protect  themselves  from  doing  themselves  bodily  injury 
during  the  attack.  The  aura  if  present  in  the  very  young  is  not 
recognized  as  such  by  them. 

2.  Initial  Cry. — The  cry  which  precedes  the  convulsive  at- 
tack is  usually  quite  pronounced.  It  may  be  hoarse  and  gut- 
tural, or  a  sharp,  shrill  cry,  followed  at  once  by  the  period  of 
spasm  and  unconsciousness. 

3.  Tonic  Spasm. — This  may  begin  as  a  twitching  of  the  facial 
muscles^  the  eyes  are  open  and  turned  up,  pupils  dilated,  con- 
junctiva insensible  and  face  pale.  The  body  is  rigid,  the  arms 
and  legs  slightly  separated  and  extended,  the  fists  clenched. 
This  stage,  lasting  less  than  a  nrinute,  is  followed  closely  by  the 
stage  of 

4.  Clonic  Convulsions. — Rhythmic  contractions  of  the  mus- 
cles of  the  face,  arms,  legs  and  body  begin,  in  the  order  named. 
There  is  stertorous  snoring  respiration,  with  accumulation  of 
foamy  saliva  in  the  mouth,  blood  tinged,  if  the  tongue  is  bitten, 
cyanosis  of  the  face  and  lips.  The  sphincters  may  be  relaxed 
with  involuntary  passage  of  urine  and  feces. 

The  active  convulsions  continue  for  two  or  three  minutes,  and 
gradually  subside;  cyanosis  is  followed  by  pallor,  the  pulse 
from  being  frequent  and  tense  becomes  feeble  and  slow,  and 
the  patient  passes  into  the 

5.  Stage  of  Unconsciousness  or  Coma. — In  this  stage  the  pa- 
tient usually  goes  into  a  profound  sleep,  lasting  often  several 
hours,  from  which  he  is  with  difficulty  aroused,  or  the  child  may 
pass  into  a  more  or  less  natural  sleep,  lasting  for  a  short  time, 
and  wakens  in  a  dazed  condition,  not  recognizing  his  surround- 
ings. A  feeling  of  depression  is  usually  felt  for  a  day  or  so 
following. 

Diagnosis  must  be  made  from  hysteria,  uremia,  Jacksonian 
epilepsy,  or  convulsions  from  reflex  irritation : 


530 


THE  DISEASES  OP    CHILDREN. 


EPILEPSY'. 

HYSTERIA. 

UREMIA. 

Aura 

none 

none 

Sudden   onset 

excitement    usually    pre- 
cedes 

gradual 

Loss  of  consciousness 

none 

yes 

Pupils      dilated,      fixed ; 

not  altered 

constricted     without 

anesthesia  conjunctiva, 

anesthesia 

eyes  rolled  up 

Tonic     convulsion     short 

rigidity    but    no    convul- 

more  condition   of   stu- 

duration 

sions 

por 

Clonic    convulsions    var- 

may be  twitchings 

none 

ious   parts   body 

Foam    on    lips,    perhaps 

none,  do  not  bite  tongue 

none 

bloody      from      biting 

tongue. 

Involuntary  passage  from 

usually  none 

none 

bladder  and  bowel 

Usually    history    of    re- 

as rule  not  as  frequent 

none 

peated  attacks 

Prolonged  stupor  follow- 

none 

none 

ing    convulsions,    may 

rare 

possible 

occur  in  sleep 

Urinary  examination  will  reveal  uremic  nature  of  convulsions. 
In  Jacksoiiian  epilepsy  the  convulsions  are  unilateral,  as  a  rule, 
perhaps  affecting  one  leg  or  arm. 

Prognosis. — Cases  rarely  recover.  The  duration,  frequency 
and  severity  of  attacks  influence  the  prognosis  greatly.  The 
outcome  is  usually  the  development  of  dementia.  The  prog- 
nosis is  worse  w'hen  epilepsy  develops  in  the  young. 

Treatment. — A  careful  investigation  must  be  made  to  ascer- 
tain, if  possible,  any  reflex  cause,  and  tliat  irritation  removed. 
The  various  systems  of  the  body  should  be  reviewed  and  inves- 
tigated carefully :  The  eye,  for  refraction  difficulties,  muscle 
irregularities;  the  nose  and  naso-pharynx,  for  deflected  septum, 
tumors,  polyps,  catarrhal  inflammation,  adenoids,  etc. ;  the  mouth 
and  gastrointestinal  tract,  for  carious  teeth,  gastric  insufficiency, 
dietetic  errors,  intestinal  autointoxication  or  parasites,  constipa- 
tion or  diarrhea;  genitourinary,  phimosis,  vesical  irritation, 
kidney  defects;  the  skin,  for  any  lesions,  etc.,  etc. 


DISEASES   OF   THE   NERVOUS   SYSTEM.  531 

The  habits  and  life  of  the  child  should  be  inquired  into  care- 
fully, the  diet  regulated,  hours  of  rest  and  sleep,  form  of  exer- 
cise and  play,  ventilation  of  bedroom,  clothing,  etc.,  must  re- 
ceive consideration.     Coffee  and  tea  should  be  prohibited. 

If  the  convulsive  attacks  are  very  frequent  and  severe,  these 
patients  do  best  in  a  home  for  epileptics  where  they  are  con- 
stantly under  observation. 

In  the  control  of  the  diet  the  method  advised  by  Richet  and 
Foulouse,^  of  withdrawal  of  salt  from  the  food  or  at  least  a 
great  diminution  in  its  use,  is  worthy  of  trial,  as  excellent  results 
have  been  reported  from  this  simple  procedure.  It  is  reported 
that  the  convulsions  are  lessened  in  frequency  and  are  much 
less  severe. 

A  large  number  of  drugs  have  been  advocated  in  the  treat- 
ment of  epilepsy,  the  most  generally  used,  and  I  might  say 
also,  abused,  being  the  bromides.  The  bromides  are  of  unques- 
tioned value,  but  they  also  are  capable  of  considerable  harm  if 
used  indiscriminately.  They  do  not  cure  the  case,  but  do  influ- 
ence the  attacks,  both  in  frequency  and  severity.  Ten  grains 
of  any  of  this  group  or  a  combination  of  the  different  salts  every 
three  hours  during  the  day,  to  a  maximum  daily  dose  of  50  to 
60  grains,  will  prove  of  benefit.  The  bromide  of  strontium  is 
one  of  the  most  efficacious  of  the  salts. 

The  fetid  breath  and  bromide  rash  are  evidences  of  satura- 
tion which  indicates  a  discontinuance  of  the  drug  temporarily. 

During  bromide  administration  careful  attention  to  the 
bowels  is  most  essential.  The  giving  of  arsenic  to  limit  the 
skin  eruption  has  been  suggested. 

Confirmed  epileptics  do  much  better  when  segregated  in  a 
country  home. 

The  decompression  operation  upon  the  brain  offers  some  re- 
lief in  certain  cases. 

DISORDERS  OF  SLEEP. 

The  new-born  infant  sleeps  20  to  22  hours  in  the  24,  unless 
disturbed  from  some  cause.  When  from  three  to  four  months 
old,  it  lies  awake  longer  periods  at  a  time  during  the  day,  but 
should  sleep  all  night,  waking  for  but  one  feeding  from  9  p.  m, 

'  Paris  Academy   of   Science,   November,    1889. 


532  THE   DISEASES   OP    CHILDREN. 

to  6  a.  m.  When  six  months  old  it  should  have  no  feeding 
at  night,  and  sleep,  from  9  p.  m.  to  6  a.  m. 

The  chief  causes  of  disturbance  of  sleep  lie  in  the  respiratory 
tract  and  the  gastrointestinal  canal. 

Catarrhal  .conditions  of  the  nose,  adenoids  and  enlarged 
tonsils  which  prevent  the  free  passage  of  air  into  the  lungs, 
cause  great  restlessness  and  loss  of  sleep.  An  elongated  uvula 
may  irritate  the  pharynx  enough  to  cause  an  incessant  coughing. 

Too  frequent  feeding,  too  rapid  nursing,  too  hot  or  too  cold 
milk,  prolonged  breast  feeding,  will  all  cause  discomfort,  from 
indigestion,  the  child  crying  out  in  sleep  and  showing  great 
restlessness. 

It  takes  an  almost  incredibly  short  tim6  for  an  infant  to 
acquire  bad  habits  of  nursing,  being  held  and  rocked  after 
feeding,  etc.,  and  a  far  greater  length  of  time  to  correct  these 
bad  habits.  Mothers  and  nurses  are  too  often  responsible  for 
restless  babies.  The  use  of  rubber  napkins  and  failure  to 
change  the  child  through  the  night  also  cause  restlessness.  Im- 
perfect ventilation,  too  little  or  too  much  cover  may  contribute 
to  sleeplessness. 

Older  children  need  the  same  routine  of  hours  for  feeding 
and  bed  as  the  infants.  Until  the  child  is  six  years  old  it  should 
be  fed  a  very  simple  supper  and  be  put  to  bed  before  7  o'clock. 
Keeping  children  up  late  or  showing  them  off  to  visitors  at  all 
hours  of  the  evening  or  night  cannot  be  too  strongly  condemned. 

Telling  exciting  stories,  threats  of  someone  getting  them  and 
dark  rooms  strike  terror  in  the  hearts  of  most  children,  and 
may  be  the  principal  cause  of  night  terrors  {pavor  nocturniis) . 
During  one  of  these  attacks  the  child  has  a  wide-eyed  stare, 
does  not  recognize  those  around,  may  cry  out,  has  hurried 
respirations,  and  is  wakened  to  consciousness  with  difficulty. 
This  condition  may  continue  for  some  time,  an  hour  or  more, 
and  the  child  fall  into  a  deep  sleep  or  waken  crying,  shortly  to 
fall  asleep  again.  As  a  rule  it  has  no  recollection  of  the  occur- 
rence on  awakening  in  the  morning. 

If  often  repeated  the  cause  of  the  disturbance  must  be  located. 
If  the  last  meal  at  night  has  been  too  large  it  must  be  regulated ; 
no  exciting  stories  or  books  or  boisterous  play  should  be  allowed. 


DISEASES   OF   THE   NERVOUS   SYSTEM.  533 

It  should  be  carefully  examined  for  any  irritation,  defect  or 
abnormality  which  may  possibly  act  as  an  exciting  cause. 

The  administration  of  a  5  or  10  grain  dose  of  the  bromides  is 
indicated  in  certain  cases  in  which  control  cannot  be  had  of 
the  case  by  eliminating  the  cause. 

ORGANIC  NERVOUS  DISEASES. 

Diseases  of  the  Peripheral  Nerves. 
There  may  be  an  inflammation  of  a  group  of  the  peripheral 
nerves,   neuritis,   or   an   involvement   of   the   entire   system   of 
peripheral  nerves,  a  multiple  neuritis. 

MULTIPLE  NEURITIS. 

Etiology. — An  intoxication  of  the  system  with  invasion  of 
the  nerve  tissue  with  microorganisms,  or  the  effect  of  the  toxins 
on  them,  is  the  active  cause,  but  exposure  to  wet  and  cold, 
trauma  or  pressure  are  predisposing  causes  most  frequently 
met  with.  Diphtheria  toxin  is  the  most  striking  example  of 
this.  Prolonged  administration  of  arsenic  and  lead  poisoning 
are  given  as  causes. 

Pathology. — Inflammation  and  degeneration  may  be  present 
in  this  condition,  and  occur  in  the  same  nerve  at  different  points. 
There  may  be  an  inflammation  of  the  sheath,  the  endonurium 
may  show  an  interstitial  neuritis  or  the  nerve  tissue  itself  a 
parenchymatous  neuritis.  In  the  latter  type  the  destruction  is 
so  great  that  the  condition  is  like  a  degeneration,  if  not  identical. 
If  the  degeneration  is  very  extensive  and  severe  there  may  be 
an  entire  destruction  of  the  nerve  tissue,  leaving  nothing  but 
the  sheath.  Secondary  degeneration  is  the  form  which  usually 
takes  place  in  the  peripheral  nerves.  If  the  cells  in  the  anterior 
horns  of  the  cord  degenerate  there  is  degeneration  also  in  the 
motor  nerves.  Regeneration  may  take  place  in  degenerated 
nerves. 

Symptoms. — ^The  typical  type  of  this  form  of  neuritis  is  that 
caused  by  the  toxin  of  diphtheria.  It  is  rare  in  infants,  but  a 
number  of  cases  have  been  reported  in  children  from  five  years 
up.  It  is  much  more  rarely  seen  since  the  general  use  of 
diphtheria  antitoxin. 


534  THE  DISEASES  OF   CHILDREN, 

The  onset  is  sudden,  with  frequently  an  initial  chill,  perhaps 
convulsions;  there  are  pains  and  sensitiveness  in  the  extremities, 
chiefly  the  lower;  fever  may  run  high,  103°  to  104°  F.  The 
child  is  extremely  weak,  and  unable  to  stand.  The  pains  con- 
tinue, the  muscles  begin  to  atrophy  and  paralysis  sets  in.  The 
reflexes  are  diminished  or  lost  entirely.  Hyperesthesia  followed 
by  anesthesia  may  occur,  the  latter  being  due  both  to  pain  and 
heat.  Some  of  the  muscles  of  the  eye  and  throat  may  be 
paralyzed.  Regurgitation  of  food  is  present  when  the  latter 
occurs.  There  is  wrist  drop  and  foot  drop  in  the  general  form. 
No  reaction  takes  place  to  the  rapidly  interrupted  current,  and 
the  reaction  to  the  galvanic  current  slow. 

Prognosis. — Regeneration  of  the  nerve  tissues  generally  takes 
place  and  recovery  occurs,  in  from  one  to  three  months. 

The  prognosis  depends  somewhat  upon  the  extent  of  the  loss 
of  electrical  reactions.  If  the  reaction  of  degeneration  is  com- 
plete the  prognosis  is  more  grave,  as  far  as  entire  restoration  of 
function  is  concerned. 

Treatment. — Complete  rest  in  bed  is  the  first  indication. 
Pain  being  one  of  the  first  and  chief  symptoms  it  is  the  first  to 
demand  attention,  if  not  relieved  by  the  application  of  heat 
it  must  be  relieved  by  an  anodyne.  Heroin,  codeine  or  one 
of  the  coal-tar  products  can  be  used,  the  latter,  however,  with 
caution.  Pyramidon  is  perhaps  the  safest.  Moist  heat  is  a 
help  in  obtaining  comfort.  Calomel  as  an  initial  remedy  is 
indicated.  Strychnia  injected  into  the  affected  muscle  has  been 
advised.  Among  the  drugs  suggested  are  the  following:  Fl.  ext, 
ergot,  3ss  to  Si ;  sodii  salicylatis,  gr.  x.  q  3  h. 

Electricity  is  of  great  service,  the  galvanic  current  being  the 
form  to  use  at  first,  but  only  after  the  acute  symptoms  have 
subsided.  After  a  month  or  six  weeks,  with  improvement  the 
faradic  current  is  indicated  in  connection  with  massage. 

FACIAL  PALSY. 

Synonym. — Bell's  Palsy. 

Tn  this  form  of  neuritis  the  seventh  nerve  is  involved. 
Etiology. — Infection,  exposure  to  cold,  rheumatism,  middle- 
ear   inflammation,   mastoid   disease   or   following   an   operation 


DISEASES   OP  THE   NERVOUS   SYSTEM.  535 

for  it,  pressure  by  forceps  blades  in  instrumental  delivery,  pro- 
longed second  stage  in  deformed  pelvis  are  given  as  causes.  If 
central,  the  process  may  be  due  to  a  meningitis,  or  brain  tumors. 

Symptoms. — The  first  symptom  may  be  pain  and  tenderness 
under  the  lobe  of  the  ear  at  the  point  of  exit  of  the  nerve,  fol- 
lowed very  soon  by  paralysis  of  motion  of  the  muscles  of  one 
side  of  the  face. 

The  characteristic  signs  of  Bell's  palsy  are  the  inability  to 
close  the  eye  on  the  affected  side,  the  eye  rotating  upward  when 
attempting  to  do  so,  inability  to  pucker  the  mouth  as  if  to 
whistle,  and  a  deflection  of  the  tongue  from  the  median  line, 
toward  the  normal  side.  Older  children  may  have  difficulty  in 
masticating  their  food.  If  the  acute  symptoms  do  not  last  very 
long  the  prospects  for  entire  recovery  are  good.  Atrophy  of 
the  muscles  may  follow. 

Diagnosis  is  chiefly  to  be  made  from  lesions  of  the  brain, 
which  is  usually  easy,  as  paralyses  of  the  upper  extremities,  one 
or  both,  are  also  apt  to  be  present. 

Prognosis. — The  majority  of  cases  recover,  practically  with 
entire  restoration  of  function  of  the  muscles.  The  duration 
is  from  six  weeks  to  five  months.  Continued  reaction  of  degen- 
eration renders  the  prognosis  less  good. 

Treatment. — In  all  cases  the  use  of  cathartics  is  indicated, 
with  rest  in  bed  or  on  the  bed  while  the  pain  under  the  ear  lasts. 
A  small  fly  blister,  one-half  inch  square,  placed  at  the  point  of 
exit  of  the  nerve  is  of  benefit. 

After  the  acute  symptoms  have  subsided  the  weak  galvanic 
current  is  used  very  gently,  and  just  strong  enough  to  contract 
the  muscles. 

If  there  is  much  contracture  of  the  mouth,  the  strain  on  the 
cheek  can  be  relieved  by  bending  soft  wire  with  a  small  hook 
at  the  end  for  the  mouth,  the  other  end  hooking  over  the  ear. 

The  administration  of  iron,  salicylate  of  soda  and  arsenic  may 
give  good  results. 

OBSTETRICAL  PARALYSIS  (Erb's). 

These  palsies  take  their  name  from  the  fact  that  they  appear 
after  manipulations  during  labor.     It  is  a  result  of  injury  to 


536  THE   DISEASES   OP    CHILDREN, 

the  brachial  plexus  of  nerves  and  occurs  when  the  head  is  pulled 
sharply  to  one  side,  or  traction  is  made  with  the  fingers  in  the 
axilla,  in  an  effort  to  deliver  the  shoulders.  It  occurs  about 
once  in  2000  labors,  and  a  small  percentage  of  the  cases  are 
bilateral. 

The  paralysis  usually  manifests  itself  about  the  third  or  fourth 
day  after  birth.  The  infraspinatus  muscle  is  most  involved. 
The  child  may  move  its  forearm  and  hand,  but  makes  no  effort 
to  move  the  arm  from  the  body.  At  first,  however,  the  whole 
arm  is  limp  and  motionless. 

If  there  is  no  improvement  the  deformity  noticed  is  a  slight 
inclination  forward  of  the  affected  shoulder,  an  atrophy  of  the 
muscles  of  the  upper  arm  and  shoulder,  and  tendency  to  an 
inward  and  forward  rotation  of  the  arm  so  the  thumb  points 
rather  backward  instead  of  forward.  The  paralysis  is  flaccid 
in  type,  and  there  is  no  tendency  at  all  to  a  spastic  condition. 

There  is  a  characteristic  electric  reaction  varying  from  a  loss 
to  the  faradic  current  to  a  complete  reaction  of  degeneration. 
If  there  is  no  faradic  response  but  the  response  to  galvanism  re- 
tained, even  if  but  feebly,  recovery  may  take  place;  if  response 
to  both  currents  is  gone  the  recovery,  if  it  takes  place  at  all,  will 
be  greatly  retarded. 

Treatment. — Nothing  is  indicated  during  the  first  two  or 
three  weeks.  At  the  end  of  this  time  gentle  rubbing,  not  deep 
massage,  should  be  begun,  with  gradually  increasing  passive 
motion.  At  the  end  of  six  to  eight  weeks,  a  very  weak  electric 
current  is  applied,  using  the  current  with  which  a  reaction  can 
be  obtained.  This  is  applied  once  a  day  or  every  other  day, 
at  first  five  minutes,  then  ten  minutes  at  a  time. 

DISEASES  OF  THE  SPINAL  CORD. 

Acute  Poliomyelitis. 

Synonyms. — Infantile  paralysis,  J  nf  an  file  spinal  paralysis. 

History.^ — This  form  of  paralysis  was  first  described  by 
Heine  in  1840,  his  writings  being  more  upon  its  end  results 
than  of  the  disease  producing  the  paralysis. 

^  Much  in  this  section  is  obtained  from  Monograph  No.  4 — June  24  of  Rockefeller 
Institute  for  Medical  Research:  "A  Clinical  Study  of  Acute  Poliomyelitis,"  by  Pea- 
body,   Draper  and   Dochez. 


DISEASES   OF   THE   NERVOUS   SYSTEM.  537 

Numerous  epidemics  were  studied  and  many  contributions 
to  the  literature  upon  it  were  made.  In  1905  Wickman  described 
the  pathology  of  the  disease  and  called  attention  to  its  epi- 
demiology. 

Etiology. — Experimental  production  of  the  disease  in  mon- 
keys was  accomplished  by  several  laboratory  workers  in  different 
countries,  in  1909,  and  their  results  published  almost  simul- 
taneously. As  a  result  of  this  work  a  bacterial  cause  has  been 
ruled  out  and  undoubted  evidence  developed  that  the  infective 
agent  belongs  to  the  so-called  filterable  virus  group.  This  virus 
is  resistant  to  many  destructive  agents,  but  is  readily  destroyed 
by  a  2  per  cent  solution  of  hydrogen  peroxide,  by  menthol  and 
corrosive  sublimate. 

Epidemiology. — Wickman  first  called  attention  to  the  abor- 
tive and  meningitic  forms  of  the  disease,  and  it  has  focused 
attention  on  a  disease  which  is  unique,  in  that  its  epidemic 
nature  is  not  caused  by  a  parasite.  It  follows  lines  of  human 
contact  and  travel,  and  the  so-called  healthy  "carrier"  is  to  be 
reckoned  with  in  its  dissemination.  There  is  every  evidence  to 
support  the  theory  that  the  port  of  entry  into  the  system  is  the 
naso-pharynx,  the  tonsils  and  the  upper  respiratory  tract.  It 
has  been  shown  that  there  is  a  direct  lymphatic  connection  be- 
tween the  naso-pharyngeal  lymphatics  and  the  subarachnoid 
space. 

The  virus  can  be  carried  on  articles  of  clothing,  bedding, 
domestic  pets,  the  fly,  and  by  dust. 

The  common  belief  among  the  laity  that  trauma  has  a  part 
in  the  etiology  can  positively  be  ruled  out. 

It  occurs  more  frequently  during  the  first  three  years  of  life, 
but  adults  are  not  immune.  It  may  occur  in  more  than  one 
member  of  a  family,  boys  are  probably  more  often  affected. 

Late  investigators  ^  claim  to  have  transmitted  the  disease  to 
mnnkoys.  They  conclude  tliat  tlio  virus  must  bo  of  protozoon 
nature. 

Epidemics  of  infantile  paralysis  are  most  frequent  in  the  late 
summer  and  early  autumnal  months.  Starr  -  has  collated  44 
epidemics  of  infantile  paralysis.     Individual  cases  may  and  often 

*  Landsteiner    and   Ponppr:    Ztschr    f    t-ti>^-  -H-^tf     „.   Exp.   Therap.,    1909,   ii,   377. 
'  Journal  American   Medical   Association,   vol.   ii,   no.   2. 


538  THE   DISEASES   OF    CHILDREN. 

develop  during  an  attack  of  acute  gastrointestinal  infection. 
It  may  also  occur  as  a  sequel  to  one  of  the  exanthemata,  par- 
ticularly scarlatina,  this  being  due  to  the  lowered  resistance  of 
the  child  and  the  increased  susceptibility  to  the  virus  of  this 
disease,  though  it  occurs  fully  as  frequently  in  the  previously 
perfectly  healthy. 

Pathology. — In  the  recent  investigations  it  has  been  shown 
that  poliomyelitis  is  a  general  infection  rather  definite  and 
constant  changes  being  found  in  other  organs  than  the  nervous 
system. 

The  meninges  are  edematous  and  injected.  The  brain  and 
cord  are  edematous  also.  The  cellular  exudate,  hemorrhage 
and  edema  are  characteristic  of  the  change  occurring  as  a  result 
of  the  action  of  this  virus. 

Any  section  of  the  cord  may  be  involved,  the  lumbar  region 
perhaps  most  frequently,  the  cervical  next  in  frequency.  The 
process  occurs  chiefly  in  the  anterior  horns  of  gray  matter, 
and  it  may  vary  from  a  simple  congestion  to  an  inflammation. 
This  part  of  the  cord  has  the  most  active  blood  supply,  and  it 
has  been  pointed  out  by  different  observers  that  the  primary 
changes  are  in  the  blood  vessels,  and  the  degeneration  which 
occurs  in  the  ganglion  cells  are  entirely  secondary.  As  a  result 
of  this  degeneration,  the  ganglion  cells  may  disappear  entirely, 
and  the  process  may  extend  to  the  entire  gray  matter,  which  is 
often  swollen  and  projects  above  the  white  matter.  These 
changes  occurring  in  the  posterior  root  ganglia  and  the  changes 
in  the  sensory  ganglia  possibly  explain  the  pain  present  in  the 
acute  stage  of  the  disease. 

The  lymphoid  tissue  of  the  body,  especially  Peyer's  patches 
and  mesenteric  glands  show  acute  swelling.  The  superficial 
glands  of  the  body,  the  tonsils,  thymus  gland  and  spleen  are 
regularly  enlarged.  Cloudy  swelling  of  other  organs  is  described 
as  present.  The  affected  muscles  show  a  characteristic  change, 
many  muscle  fibers  disappear  entirely  and  the  others  are 
shrunken,  the  whole  limb  being  atrophied,  even  the  bone  being 
smaller  than  that  of  the  unaffected  side. 

Symptoms. — The  following  clinical  types  have  been  described 
by    Wickman:    (1)    spinal    poliomyelitic    form,    (2)    Landry's 


DISEASES   OF   THE   NERVOUS   SYSTEM.  539 

paralysis  type,  (3)  bulbar  or  pontine  form,  (4)  the  encephalitie 
form,  (5)  the  ataxic  form,  (6)  the  neuritic  form,  (7)  the 
meningeal  form,  (8)  the  abortive  type.  Peabody,  Draper  and 
Dochez  advocate  the  classification  into  three 'main  groups:  (1) 
those  cases  in  which  the  upper  motor  neurone  is  primarily 
affected,  the  cerebral  group;  (2)  the  larger  group  of  cases  in 
which  the  lower  motor  neurone  is  involved,  the  bulbospinaf 
group;  and  (3)  the  abortive  cases,  which  do  not  become  par- 
alyzed. It  is  more  often  seen  in  the  robust,  and  if  not  as- 
sociated with  other  diseases  is  like  an  infectious  disease  in  its 
onset.  The  period  of  incubation  is  very  variable,  but  from  ob- 
servation of  cases  occurring  in  the  same  family  it  is  believed 
to  be  from  one  to  four  days.  There  are  nearly  always  some 
prodromata;  the  child  may  awaken  in  the  night,  after  a  period 
of  restlessness  or  perhaps,  there  has  been  listlessness  during  the 
previous  two  or  three  days.  There  may  be  anorexia,  nausea  or 
vomiting  and  fever  to  102°  F.  or  104°  F.  and  in  those  so  inclined, 
even  convulsions.  A  chill  is  comparatively  rare.  Sweating  is 
sometimes  present.  Pain  is  present  in  the  back  of  the  head  and 
in  the  affected  muscles.  The  acute  symptoms  last  two  or  three 
days,  during  which  time  muscular  weakness  is  present,  when 
the  paralysis  is  noted.  Fever  may  continue  for  a  week.  Diar- 
rhea is  seen  often.  The  skin  is  very  active.  In  contrast  to  the 
cases  with  severe  prodramata  there  are  cases  which  show  but 
little  indisposition,  the  paralysis  being  the  first  symptom  noted, 
and  the  paralysis  may  be  as  severe  in  these  cases  as  in  the  others. 
]\liiller  claims  there  is  a  leucopenia  present,  but  later  authorities 
do  not  think  it  is  a  sign  to  be  relied  upon.  There  is  a  moderate 
increase  in  the  pressure  of  the  spinal  fluid  when  lumbar  puncture 
is  done,  and  increase  in  the  number  of  cells  per  cubic  milli- 
meter; the  type  of  the  cells  may  be  either  mononuclear  or  poly- 
nuclear.  The  absence  of  the  bacteria  present  in  the  spinal  fluid 
in  other  meningitic  infections  make  this  method  of  diagnosis 
more  important. 

In  the  usual  form  as  described  by  Peabody,  Draper  and 
Dochez,  the  paralysis  appears  on  the  first  or  second  day  of  the 
disease.  The  child  is  drowsy  and  lies  on  its  back  with  legs 
slightly  flexed  and  everted.     It  can  be  roused  by  the  gentlest 


540  THE  DISEASES   OP    CHILDREN. 

touch  or  manipulation  of  an  extremity.  If  it  is  the  paralyzed 
limb  which  is  moved  tl^e  child  will  attempt  to  free  it  from  the 
examiner 's  hand  by  a  twisting  motion  of  the  body  and  shoulders, 
which  is  accompanied  by  a  fretful  look  and  whine.  When  there 
is  more  meningeal  irritation  the  position  assumed  is  usually 
upon  the  side  with  more  or  less  retraction  and  rigidity  of  the 
neck  or  opisthotonos.  Crying  or  fretfulness  may  begin  as  soon 
as  the  bed  is  approached.  Ocular  paralyses  may  be  present, 
sometimes  photophobia.  The  throat  is  usually  congested  and 
tonsils  swollen,  tongue  coated,  enlargement  of  superficial  lymph 
nodes.  Most  rales  may  be  found  in  the  chest  without  coincident 
temperature. 

The  paralysis  makes  its  appearance  rather  suddenly  as  a  rule. 
In  infants  it  may  be  recognized  only  after  prolonged  watching 
at  the  bedside. 

The  reflexes,  both  superficial  and  deep,  vary  considerably. 
Sweating,  both  general  and  localized,  may  be  present.  Reten- 
tion of  urine  may  be  seen.     Constipation  is  the  rule. 

Pain  is  a  constant  feature  and  a  symptom  which  is  not  gen- 
erally attributed  to  this  form  of  paralysis.  Three  types  are 
described  :  pain  on  manipulation ;  spontaneous  pain ;  and  tender- 
ness on  pressure  over  the  muscles  and  nerve  trunks.  As  stated 
a  few  cases  may  be  seen  in  which  the  illness  apparently  began 
with  the  paralysis.  Their  appearance  and  symptoms  are  much 
as  the  type  just  described. 

In  the  so-called  meningitic  or  cerebral  form  there  is  a  marked 
disturbance  of  the  sensorium.  Profound  stupor  follows  the 
drowsiness  of  the  ordinary  form,  and  the  picture  is  much  that 
of  a  patient  with  tubercular  meningitis,  and  it  may  require  a 
tuberculin  test  to  differentiate.  After  a  varying  length  of  time, 
the  stupor  clears  up,  the  child  passing  through  a  period  of 
fretfulness  and  irritability. 

Paralyses. — The  paralysis  is  of  the  flaccid  type,  of  lower 
neurone  destruction,  without  contractures,  associated  very  soon 
with  atrophy,  the  electric  reactions  are  altered,  the  sensation  is 
not  greatly  impaired  though  it  may  be  tender  and  the  reflexes 
diminished  or  lost  in  the  affected  limb.  The  affected  part  is  cold 
and  often  cj^anosed. 


DISEASES   OF   THE   NERVOUS   SYSTEM.  541 

The  paralysis  at  first  may  involve  the  entire  extremity,  and  as 
the  inflammation  or  congestion  subsides  restoration  of  function 
in  all  but  a  single  muscle  or  group  of  muscles  takes  place.  This 
is  a  characteristic  symptom  of  infantile  paralysis.  This  im- 
provement usually  occurs  within  the  first  three  months. 

The  atrophy  is  progressive  until  the  difference  in  the  two  sides 
is  quite  marked.  The  chief  cause  of  deformities  is  the  strength 
of  the  opposing  muscles. 

The  paralyses  are  not  symmetrical  in  their  distribution,  as 
one  leg  and  one  arm  may  be  affected  or  the  perineal  muscles 
of  one  side  and  the  face. 

The  electrical  reaction  is  that  of  complete  degeneration,  com- 
plete loss  of  faradic  and  galvanic  response  in  the  nerves,  and 
delayed  galvanic  response  in  the  muscles. 

Diagnosis. — In  many  cases  the  diagnosis  is  not  made  until 
the  development  of  the  paralysis.  The  acute  condition  may  be 
mistaken  for  any  of  the  acutfe  intoxications  according  to  the 
predominance  of  the  symptoms.  The  chief  condition  which  may 
be  confused  with  infantile  paralysis  is  cerebrospinal  meningitis, 
but  the  convulsions  of  infantile  paralysis  occur  only  at  the  on- 
set, and  none  of  the  other  meningeal  symptoms  are  present. 

In  the  acute  cerebral  palsies  the  chief  diagnostic  symptom 
is  the  spastic  nature  of  the  palsy,  without  atrophy;  its  hemi- 
plegic  nature;  the  normal  electric  reaction,  with  not  infrequent 
involvement  of  the  mind.  The  reflexes  in  the  cerebral  type  are 
exaggerated  also. 

In  neuritis  the  pain  is  a  prominent  symptom,  which  is  usually 
less  in  poliomyelitis,  but  in  other  respects  the  symptoms  are 
much  the  same,  viz.,  paralysis,  atrophy  and  electrical  phe- 
nomena. 

Prognosis. — The  mortality  in  sporadic  cases  is  small,  and  in 
epidemics  from  6  to  10  per  cent.  In  Wickman's  series  of  868 
cases  the  mortality  was  16.7  per  cent.  Death  occurs  most  often 
on  the  fourth  day  of  the  paralysis,  though  they  are  not  out  of 
danger  until  after  the  eighth  day  from  the  beginning  of  the 
muscular  weakness.  There  is  no  way  of  giving  an  accurate 
prognosis  in  the  beginning  of  an  attack,  as  often  a  very  hopeless 
looking  case   will  show  regeneration  of  a  number  of  muscles 


542  THE   DISEASES  OP    CHILDREN. 

which  at  first  showed  complete  paralysis.  The  family  should, 
however,  be  put  in  complete  possession  of  facts,  and  the  possible 
outcome,  emphasizing  the  favorable  symptoms  always,  but  there 
is  absolutely  no  way  of  anticipating  the  paralysis.  A  number 
of  cases  have  been  reported  showing  complete  recovery. 

Treatment. — Steps  must  be  taken  at  once  the  diagnosis  is 
made  to  establish  a  strict  quarantine.  In  view  of  the  fact 
that  the  virus  in  experimental  work  on  monkeys  has  been 
found  rarely  to  persist  after  three  weeks,  it  is  safe  to  isolate 
affected  children  for  four  weeks  from  the  beginning  of  the  attack. 
In  the  acute  stage  dry  cups  along  the  spine  may  be  beneficial. 
Hydrotherapy  is  of  great  benefit.  In  this  stage  an  anodyne  is 
needed  for  the  pain  unless  it  is  controlled  by  the  application 
of  a  splint  or  bandage.  The  application  of  an  ice  bag  to  the 
spine  is  of  great  benefit  and  comfort.  Absolute  rest  in  bed  is 
the  chief  indication. 

Attention  should  be  given  to  the  bowels,  an  initial  calomel 
purge  being  of  benefit.  The  diet  should  be  bland  and  easily 
digested,  and  a  minimum  of  sweets  given. 

Careful  nursing  by  a  trained  and  competent  nurse  should  be 
insisted  upon. 

With  the  first  evidence  of  contracture  of  opposing  muscles 
enough  to  cause  deformity,  a  brace  should  be  so  applied  as  to 
overcome  this,  or  the  leg  held  in  place  by  sand  bags.  If  the  con- 
traction is  very  great  before  the  brace  is  applied,  a  tenotomy  of 
the  opposing  muscle  should  be  performed,  followed  by  applica- 
tion of  a  plaster  of  dressing  with  the  part  being  slightly 
over-corrected. 

Massage  is  of  great  service  after  the  acute  symptoms  have 
begun  to  subside,  to  exercise  the  flaccid  muscles.  Muscle  train- 
ing is  of  great  assistance.  Electricity  is  to  be  used  for  this 
purpose  also.  In  the  early  stages  galvanism  should  be  used  on 
the  nerve  trunks  and  faradism  on  the  muscles  so  long  as  their 
irritability  for  contraction  is  maintained.  When  irritability 
of  contraction  to  the  faradic  is  lost  galvanism  should  be  used. 
It  should  not  be  applied  oftener  than  once  a  day,  10  or  15 
minutes  at  a  time,  and  continued  for  several  months,  and  should 
be  used  only  by  those  expert  in  its  application. 


DISEASES   OF   THE   NERVOUS   SYSTEM,  543 

Much  has  been  accomplished  in  the  last  few  years  in  the 
treatment  of  marked  deformities  in  the  transplantation  of  ten- 
dons, for  the  technic  of  which  the  reader  is  referred  to  any 
of  the  late  works  on  surgery. 

Not  much  improvement  can  be  looked  for  for  several  weeks, 
when  an  evidence  of  regeneration  will  show  by  return  of  function 
in  some  muscles.  It  is  advised  to  give  hexamethylenamine,  gr. 
V,  every  four  hours,  to  child  of  eight  years  (Gushing).  Salicy- 
late of  sodium  or  strontium  can  be  used  to  advantage. 

ACUTE  MYELITIS. 

An  inflammation  of  the  entire  substance  of  the  cord,  in  a 
transverse  section,  or  over  an  extensive  area. 

Etiology. — ^This  is  essentially  an  acute  infection,  occurring 
independently  or  as  a  sequel  to  one  of  the  acute  infectious  dis- 
eases or  exanthemata.  It  may  also  result  from  an  extension 
downward  of  a  primary  meningeal  lesion.  Congenital  syphilis 
and  Pott's  disease  are  among  the  active  causes.  Trauma,  re- 
sulting in  pressure  or  hemorrhage  into  the  cord  may  be  the 
cause.  The  causes  given  in  the  adult  form,  as  alcohol,  lead, 
mercury,  etc.,  can  practically  be  eliminated  in  children. 

Pathology. — There  is  no  regularity  in  the  extent  of  involve- 
ment or  limitation  of  the  segments  involved,  as  two  or  more 
portions  of  the  cord  may  be  affected  with  normal  tissue  between. 
The  dorsal  portion  has  been  found  most  often  involved.  The 
chief,  and  perhaps  primary,  changes  are  in  the  blood  vessels,  the 
blood  supply  is  interfered  with,  there  are  minute  hemorrhages 
in  the  gray  matter  and  softening  occurs.  The  meninges  are 
congested  and  swollen.  The  white  and  gray  matter  are  not 
distinct.  The  cord  substance  is  destroyed  and  is  soft  and  creamy 
in  consistence.  The  process  described  extends  to  the  nerve  roots 
also. 

Symptoms. — These  vary  greatly,  and  because  of  the  variety 
in  symptoms  the  eases  have  been  grouped  into  acute,  subacute 
and  chronic  forms. 

In  the  acute  form  the  onset  is  sudden,  and  if  of  septic  origin 
it  begins  with  a  chill  and  fever,  usually  above  102°  F.  There 
is  pain  in  the  back,  varying  with  the  site  of  the  lesion.  Tender- 
ness over  the  affected  area  is  also  present.     If  there  is  an  entire 


544  THE   DISEASES  OP    CHILDREN. 

transverse  inflammation  the  function  of  all  muscles  below  this 
level  are  interfered  with,  including  the  sphincters.  If  the  upper 
part  of  the  cord  is  affected  the  arms  are  also  paralyzed.  Com- 
plete anesthesia  is  present  extending  to  a  level  of  the  lesion.  AH 
sensations,  thermal,  muscular  pain  and  touch,  are  absent,  and 
the  patient  does  not  feel  as  if  the  extremities  were  a  part  of 
him. 

If  the  lesion  is  in  the  cervical  portion  of  the  cord  the  par- 
alysis of  the  arms  will  be  flaccid  and  of  the  lower  extremities 
spastic  in  character.  If  the  lower  portion  of  the  cord  is  affected 
the  paralysis  is  of  the  lower  extremities  and  is  of  the  flaccid 
type,  with  loss  of  reflexes  but  without  involvement  of  the  arms. 
Trophic  lesions  wall  often  develop  in  these  cases,  with  develop- 
ment of  bed  sores.  If  these  are  large  and  absorption  from  them 
possible,  the  temperature  will  be  influenced. 

In  male  children  priapism  may  be  present  in  lumbar  involve- 
ment, and  in  all  cases  disturbances  of  bladder  and  rectum  take 
place.  Involuntary  passages  of  urine  and  feces  frequently  occur, 
though  retention  of  urine  is  perhaps  more  frequently  followed 
by  cystitis. 

Diagnosis. — The  clinical  picture  presented  is  fairly  typical 
of  this  form  of  lesion.  In  hemorrhage  into  the  cord  the  onset 
of  the  trouble  is  more  sudden,  without  fever  and  without  loss  of 
reflexes,  atrophy  or  reaction  of  degeneration.  In  hemorrhage 
the  pain  is  not  so  great,  if  present  at  all. 

In  multiple  neuritis,  if  all  of  the  extremities  are  involved, 
the  paralysis  is  the  same,  while  in  myelitis  the  paralysis  may  be 
flaccid  in  the  upper  and  spastic  in  the  lower  extremities. 

Prognosis. — A  guarded  prognosis  should  always  be  given. 
The  more  extensive  the  involvement  and  acute  the  symptoms 
the  graver  the  prognosis.  The  early  development  of  complica- 
tions, as  bed  sores,  cystitis,  etc.,  make  the  prognosis  graver. 

In  the  subacute  variety,  regeneration  may  take  place  to  some 
extent  in  the  cord,  and  restoration  of  function  to  a  certain 
extent  be  possible.  In  syphilitic  cases  good  results  are  obtained 
from  specific  treatment. 

The  younger  the  child  the  graver  the  prognosis. 

Treatment. — The  child  will  usually  have  been  put  to  bed 


DISEASES   OP   THE   NERVOUS   SYSTEM.  545 

when  first  seen.  If  a  young  child,  positive  orders  must  be  given 
that  it  be  not  taken  from  the  bed  and  held  or  rocked  under 
any  circumstances. 

Local  application  of  cold  by  a  long  ice  bag  is  of  service  and 
should  be  applied  intermittently.  The  tendency  to  trophic  dis- 
orders should  be  remembered,  and  the  long-continued  applica- 
tion not  allowed.  The  bladder  and  bowels  must  be  closelj^ 
watched.  Extra  precautions  must  be  taken  if  catheterization 
is  needed.  The  position  of  the  child  must  be  changed  often  and 
the  skin  of  the  dependent  parts  closely  guarded  against  bed 
sores.  Most  careful  attention  must  be  given  the  bed  sore  if 
the  skin  breaks  down.  Ichthyol  ointment,  3  or  5  per  cent,  or 
balsam  of  Peru  (M.  xx)  and  castor  oil  (§1)  are  good  dressings 
in  these  cases.  A  water  bed  or  air  mattress  may  prevent  the 
development  of  bed  sores. 

If  improvement  is  shown  the  child  must  be  carefully  watched 
to  keep  it  from  using  the  affected  "parts.  Judicious  massage 
and  rubbing  should  be  used  for  exercise. 

In  the  syphilitic  cases  the  early  administration  of  appropriate 
remedies  is  indicated. 

Tonic  treatment,  especially  out-of-door  air,  is  indicated.  If 
contractures  develop,  tenotomy  and  the  proper  orthopedic 
measures  used  to  prevent  and  correct  them. 

POTT'S  DISEASE. 

No  attempt  is  made  to  describe  the  condition  of  Pott's  disease 
from  the  standpoint  of  the  orthopedic  surgeon,  but  only  as 
relates  to  the  changes  it  produces  in  the  spinal  cord.  It  is  a 
fairly  common  condition  in  childhood,  and  is  due  to  a  tubc^r- 
cular  osteitis. 

Owing  to  softening  of  the  bony  and  intervertebral  cartilage  an 
angulation  takes  place  in  the  spinal  column,  its  lumen  is  nar- 
rowed and  pressure  is  made  on  the  cord.  Yet  it  is  surprising 
how  great  the  deformity  may  be  without  any  pressure  symp- 
toms presenting.  The  inflammatory  condition  from  the  bone 
extends  to  the  meninges  and  thence  to  the  cord,  or  pressure 
symptoms  may  be  present  from  the  meningeal  involvement  alone. 

The  cord  may  be  softened  and  degeneration  of  the  cord  is 


546 


THE   DISEASES   OF    CHILDREN. 


found  above  and  below  the  point  of  pressure, 
condition  is  present  as  in  myelitis. 


Much  the  same 


Fig.    85. — X-ray    of    Pott's    disease    involving    first    lumbar    and    last    dorsal    vertebrae. 


SyTnptoms. — The  development  of  this  condition  is  very  slove 
as  a  rule.  Spastic  paralysis  is  an  early  symptom  and  may  be 
the  first  noted.     Sensitiveness  and  pain  are  present  when  pres- 


DISEASES   OP   THE   NERVOUS   SYSTEM.  547 

sure  is  made,  due  to  involvement  of  the  nerve  roots.  Disturbed 
sensation  may  also  be  present. 

Diagnosis. — This  is  to  be  made  principally  from  myelitis. 
A  careful  examination  of  the  spine  for  deformity  or  rigidity 
should  always  be  made  in  cases  of  suspected  spinal  cord  lesion. 
In  Pott's  disease  there  is  pain  on  pressure  over  the  involved 
vertebra.  In  those  cases  in  which  the  paralysis  precedes 
the  deformity  the  diagnosis  may  be  difficult. 

Prognosis. — If  the  paralysis  is  entirely  due  to  the  pressure, 
with  but  little  inflammation  present  in  the  cord,  the  process 
may  be  stopped  by  proper  orthopedic  measures,  taken  to  relieve 
the  deformity  and  pressure,  by  properly  fitting  appliances. 
However,  the  case  is  apt  to  be  progressive,  and  the  outlook  for 
recovery  very  grave. 

Treatment. — The  firat  positive  indication  is  to  relieve  the 
pressure  by  prompt  orthopedic  measures.  Perhaps  rest  in  bed, 
entirely  recumbent,  may  influence  the  condition,  or  in  other 
cases  plaster  of  Paris  jackets  are  indicated. 

Fresh  air,  tonics,  good  food  and  hygiene  are  the  chief  indica- 
tions other  than  the  surgical  ones. 


TUMORS  OF  THE  SPINAL  CORD  AND  ITS  COVERINGS. 

These  growths  are  very  rare  in  childhood.  Syphilis  and 
tuberculosis  cause  the  majority.  Malignancy  may  be  the  cause. 
Cysts  and  gliomata  are  also  given  as  causes,  the  former  due  to 
hemorrhage. 

Symptoms. — The  onset  is  very  gradual,  the  symptoms  vary- 
ing according  to  location  of  the  tumor.  If  the  meninges  are 
principally  involved  there  is  pressure  on  the  posterior  roots 
and  pain  later  after  involvement  of  the  meninges  and  roots  takes 
place.  Not  infrequently  only  half  of  cord  may  be  involved. 
The  cervical  and  dorsal  regions  are  perhaps  most  often  affected. 
There  is  flaccid  paralysis  of  one  or  both  arms  w^hen  located  high 
up,  and  of  the  legs  when  lower  in  the  cord.  Atrophy  soon 
develops  in  each. 

Diagnosis. — In  Pott's  disease  the  deformity  is  usually  present 
and  the  course  of  the  disease  is  longer.     In  myelitis  the  course 


548  THE   DISEASES   OF    CHILDREN. 

is  much  more  rapid,  pain  is  not  so  prominent  and  paralysis 
sooner. 

In  neuritis  paralysis  is  present  earlier  and  the  rectum  and 
bladder  not  involved. 

Prognosis. — This  is  unfavorable,  as  surgery  offers  but  little 
hope.  In  syphilitic  tumors  some  good  may  be  accomplished  by 
proper  treatment. 

Treatment. — Except  in  syphilitic  tumors,  drugs  are  of  no 
avail.  The  iodides  and  mercury  should  be  tried  in  every  case, 
but  their  efficacy  is  doubtful.  Operation  for  removal  of  the 
tumor  should  be  performed  if  all  other  remedies  fail,  though 
it  is  an  operation  with  but  little  hope  of  relief,  and  most  diffi- 
cult to  perform. 

SYPHILIS  OF  SPINAL  CORD. 

The  infant,  the  subject  of  hereditary  syphilis,  is  apt  to  de- 
velop this  condition  more  often  than  if  it  is  acquired. 

Pathologfy. — ^An  involvement  of  the  arteries  is  the  most  fre- 
quent lesion,  an  endarteritis  or  arteritis  causing  softening  of 
the  cord  substance,  as  in  myelitis.  A  meningitis  is  present,  also 
gummata  in  the  cord  and  brain. 

Symptoms. — ^These  are  not  like  those  present  in  conditions 
just  described.  The  onset  is  gradual;  the  paralyses  follow  a 
period  of  weakness  of  the  muscles  and  inability  to  walk,  and  are 
more  apt  to  be  of  the  spastic  variety.  Pain  or  anesthesia,  or 
both,  are  present,  varying  according  to  the  involvement  of  the 
roots.  Eeflexes  are  usually  increased,  sphincteric  reflexes  may 
be  interfered  with. 

Usually  there  is  an  irregular  distribution  of  the  disease  over 
the  greater  part  of  the  cord.  The  dorsal  enlargement  is  most 
often  and  severely  affected.  The  process  spreads  irregularly 
to  other  portions  of  the  cord,  evidenced  by  irregular  areas  of 
loss  of  sensation  here  and  there  on  trunk  and  extremities. 

Diagnosis. — This  is  chiefly  from  myelitis.  The  history  of 
syphilis  or  its  manifestations  in  other  parts  of  the  body  is  an 
aid  in  diagnosis.  In  myelitis  a  whole  cross-section  of  the  cord 
is  involved,  and  symptoms  are  the  same  on  both  sides  below 
the  level  of  the  lesion;  in  syphilis  the  invasion  of  the  cross- 


DISEASES  OP   THE   NERVOUS   SYSTEM.  549 

section  of  the  cord  is  slow.  Erb's  statement  that  in  syphilis 
there  may  be  complete  paralysis  with  but  slight  anesthesia  and 
slight  rigidity  should  also  be  remembered. 

In  infantile  spastic  paraplegia  the  early  appearance  of  the 
trouble  and  the  absence  of  particular  sensory  symptoms  makes 
the  diagnosis  clear. 

In  infantile  paralysis  there  is  but  little  pain,  and  the  irregular 
distribution  of  the  paralysis,  as  the  right  arm  and  left  leg,  with 
the  absence  of  sensory  symptoms  rules  out  syphilis. 

Treatment. — Mercurials  and  iodides  are  positively  indicated, 
and  the  earlier  they  are  given  the  better  the  prognosis.  In  the 
child  the  inunction  of  mercury  is  the  best  method  of  administra- 
tion, with  gradually  increasing  doses  of  the  iofdide  of  potash. 
Fifty  per  cent  ung.  hydrargyri,  with  vaseline  or  lanolin,  can 
be  used,  rubbing  a  piece,  the  size  of  a  small  hazel  nut  into  the 
flexures  and  groin  once  daily. 

With  the  development  of  acute  coryza  the  iodides  should  be 
discontinued  temporarily,  and  when  resumed,  begin  with  the 
minimum  dose,  and  increase  as  before. 

DISSEMINATED  SCLEROSIS. 

Synonyms. — Multiple  cerebrospinal  and  insular  sclerosis. 

According  to  Fotzke  this  disease  may  be  manifest  at  birth  or 
develop  during  the  first  year,  but  the  larger  number  of  cases 
are  seen  during  the  second  decade. 

Etiology. — The  infectious  diseases  are  considered  the  most 
frequent  causes.  Among  the  other  causes  may  be  mentioned 
trauma,  heredity  and  metallic  poisoning  (Oppenheim). 

Pathology. — There  are  irregular  patches  of  sclerosis  at  vari- 
ous points  in  the  central  nervous  system,  brain,  pons,  medulla 
and  cord.  The  growth  is  of  fibrous  tissue,  an  increase  in  neu- 
roglia tissue.     Some  changes  take   place  in  the  blood  vessels. 

Symptoms. — Following  a  brief  period  of  weakness  of  the 
lower  extremities,  and  sometimes  the  upper,  there  develops  an 
intention  tremor  which  is  very  noticeable.  It  is  only  present 
when  the  patient  wills  to  make  a  movement,  and  in  an  effort  to 
accomplish  it  the  tremor  takes  place.  The  tremor  becomes  so 
marked  that  the  patient  cannot  feed  himself  or  drink  from  a 


550  THE   DISEASES  OP   CHILDREN. 

glass  held  in  oue  or  both  hands.  Next  develops  a  difficulty  in 
speech,  which  has  been  designated  scanning  speech.  He  speaks 
very  slowly  and  deliberately. 

The  eye  symptoms  are  fairly  characteristic.  Nystagmus  de- 
velops early,  especially  when  looking  from  one  side  to  the  other. 
The  visual  field  is  narrower.  The  mind  becomes  affected  rather 
early.     Hysterical  attacks  are  common,  memory  is  bad. 

The  lower  extremities  develop  a  spastic  paralysis,  which 
greatly  interferes  with  walking. 

There  are  no  distinct  or  typical  electrical  reactions,  the 
sphincters  are  not  involved  and,  as  a  rule,  atrophy  of  muscles 
does  not  take  place  unless  there  is  sclerosis  of  the  anterior  horns, 
which  occurs  less  frequently. 

Diagnosis. — In  myelitis,  sphincter  relaxation  and  sensory  phe- 
nomena are  prominent  symptoms. 

The  association  of  the  usual  symptoms,  intention  tremor, 
scanning  speech,  mental  symptoms  and  spastic  paralysis  are 
sufficient  to  make  the  diagnosis. 

Prognosis. — The  condition  is  incurable  and  it  is  essentially 
a  chronic  disease. 

Treatment. — The  patient  should  have  a  protracted  rest  in 
bed  as  soon  as  the  diagnosis  is  made,  especially  if  there  is  a 
decided  intention  tremor.  General  tonic  treatment  is  of  benefit, 
including  hydrotherapy,  electricity  and  massage,  all  intelli- 
gently applied. 

HEREDITARY  ATAXIA. 

Synonyms. — Friedreich's  disease;  family  disease  of  the  cord. 

Etiology. — This  is  essentially  a  disease  of  early  life,  develop- 
ing in  the  majority  of  cases  before  the  tenth  year.  It  is  believed 
by  some  to  be  primarily  due  to  an  arrest  of  development  of  the 
cord.  It  may  occur  in  several  generations,  and  often  several 
are  affected  in  the  same  family,  and  usually  of  the  same  sex. 

Pathology. — The  process  is  principally  located  in  the  pos- 
terior and  lateral  columns,  though  the  entire  cord  is  smaller 
than  normal.  The  process  is  principally  a  sclerosis,  either  lo- 
cated entirely  in  the  column  of  Goll  or  the  columns  of  Burdaeh 


DISEASES  OP  THE  NERVOUS  SYSTEM.  551 

or  both,  and  generally  the  entire  length  of  the  cord  is  affected. 

Symptoms. — Generally  the  first  symptom,  if  it  is  not  present 
at  birth,  is  a  peculiar  gait,  the  child  being  unsteady  and  awk- 
ward on  its  feet.  It  balances  itself  with  feet  separated,  and  the 
gait  is  much  as  it  is  in  locomotor  ataxia.  Following  this  man- 
ifestation in  the  lower  extremities,  a  spastic  condition  develops 
in  them,  and  a  loss  of  power  in  the  upper  extremities  and  a 
jerky  movement  of  them  when  an  attempt  is  made  to  grasp  or 
pick  up  an  object.  Nystagmus  may  be  present  at  this  time 
also  ptosis  and  strabismus  may  be  present.  The  child  talks 
thickly  and  later  cannot  be  understood.  Sensation  is  rarely 
interfered  with.  Deep  reflexes  are  not  present  as  a  rule,  the 
patellar  reflexes  cannot  always  be  elicited. 

Deformities  develop  after  the  spastic  stage  sets  in,  particu- 
larly in  the  feet,  the  great  toes  being  hyperextended,  the  other 
toes  to  a  lesser  degree. 

Mentality  is  much  interfered  with  as  the  disease  progresses. 

Diagnosis. — Tabes  resembles  this  form  of  ataxia,  but  it  is 
practically  never  seen  in  children.  In  vnuliiple  sclerosis,  the 
intention  tremor  and  marked  spastic  gait  are  diagnostic  signs. 

Prognosis. — These  cases  grow  progressively  worse  until  they 
are  comi^letely  helpless,  but  life  is  often  prolonged  for  years. 

Treatment. — Nothing  can  be  done  to  influence  the  course  of 
the  disease.  The  patient  can  be  made  comfortable  by  attention 
to  hygiene,  diet,  etc.,  correction  of  deformities  by  section  of 
contracted  tendons,  etc.,  and  medicinal  treatment  given  as  symp- 
toms arise. 

HEREDITARY  SPASTIC  PARALYSIS. 

A  condition  occurring  as  a  family  characteristic,  in  which 
there  is  a  spastic  paralysis  chiefly  affecting  the  lower  extrem- 
ities, more  rarely  the  upper. 

Cases  present  different  symptoms  according  to  the  chief  loca- 
tion of  the  pathological  lesion,  cerebral  or  spinal,  or  a  combina- 
tion of  both. 

In  the  spimtl  type  the  chief  symptoms  are  spastic  paraplegia, 
with  contractures  and  increased  reflexes,  and  the  pathologic  proc- 


552  THE   DISEASES   OF    CHILDREN. 

ess  is  located  in  the  pyramidal  tracts  of  the  lateral  columns.  In 
this  type  there  is  no  evidence  of  cerebral  involvement. 

In  the  cerebral  type  the  first  symptom  to  call  attention  to 
abnormality  is  an  arrested  cerebral  development.  If  the  disease 
develops  early  the  child  will  not  show  the  normal  intellection 
of  its  age,  or  if  older  will  soon  develop  idiocy.  Blindness  is 
often  present.  They  are  classed  under  the  term  amaurotic 
family  idiocy.  If  of  the  cerebrospinal  type  the  spastic  condition 
above  referred  to  develops  in  addition  to  the  idiocy. 

Diagnosis. — The  hereditary  nature  of  the  disease  is  character- 
istic. In  congenital  paralysis  there  is  a  history  of  convulsions, 
and  usually  of  a  diflBcult  labor,  and  no  hereditary  history. 

Prognosis. — These  cases  may  live  for  years,  but  the  outlook 
for  recovery  of  mind  is  hopeless. 

Treatment  is  entirely  of  no  avail,  and  is  symptomatic. 

PROGRESSIVE  MUSCULAR  DYSTROPHY. 

Synonyms. — Primary  myopathy,  Idopathic  muscular  atrophy. 

A  condition  in  which  there  is  a  progressive  muscular  weak- 
ness of  a  certain  group  of  muscles;  associated  with  atrophy. 

Etiology. — This  is  a  family  disease,  several  members  being 
often  affected,  the  transmission  being  through  the  mother. 

Pathology. — The  pathology  is  chiefly  in  the  muscles,  the 
fibers  being  atrophied,  the  sheath  being  often  filled  with  fat- 
The  spinal  cord  and  nerves  are  normal.  In  the  pseudohyper- 
trophic form  there  is  also  an  increase  in  fat  between  the  fibers 
and  an  increase  in  the  connective  tissue. 

Symptoms. — Three  types  are  generally  described,  pseudo- 
hypertrophy of  the  muscles;  juvenile  type  (Erb's)  ;  and  Land- 
ouzy-Dejerine's  type,  the  latter  the  facioscapulo-huraeral  variety. 

In  the  Landonzy-Dejerine's  type  the  principal  groups  of 
muscles  involved  are  those  of  the  face  and  shoulder  girdle.  The 
first  muscle  to  atrophy  is  the  orbicularis  oris,  followed  by  the 
other  facial  muscles  and  of  the  shoulder  girdle. 

Sachs  ^  has  given  the  following  tabular  description  of  the 
three : 


*  Sachs:   Nervous    Diseases   of   Children. 


DISEASES   OP  THE   NERVOUS   SYSTEM. 
TYPES    OF    PRIMARY    DYSTROPHIES. 


553 


MUSCULA3 

JUVENILE  FOBM  OF 
PROGRESSIVE 

TYPE  LANDOUZY- 

PSEUDO- 
HYPEBTBOPHY 

MUSCULAB  ATRO- 
PHY (EBB'S  TYPE) 

DEJEEINE 

Part   first   affected    

Legs      (calves). 

Shoulder  girdle 

Face  and  shoul- 

der girdle. 

Distribution 

of    hypertro- 

Calves,      rarely 

Muscles   around 

None. 

phv    

thighs. 

shoulder    gir- 

IT     J 

dle    and    pel- 

vic girdle. 

Distribution 

of   atrophy.. 

Thighs,      deep 

Thighs,      deep 

Face       muscles, 

muscles  of 

muscles  of 

including  lips 

back,      shoul- 

back,     upper 

and       orbicu- 

der, and  scap- 

arm.    Hyper- 

laris       palpe- 

ular   muscles. 

trophied 

b  r  a  r  u  m   ; 

Calves  during 

parts      may 

shoulder    and 

later    period ; 

become    atro- 

scapular 

at   that   time 

phic   in   later 

muscles. 

also  general 

stage. 

atrophy. 

Parts  remaining  normal.. 

Face,     forearm. 

Face,     forearm. 

Forearm,    hand 

and  hand,  ex- 

hand and  leg 

and  legs,  and 

cept    in    last 

muscles       ex- 

deep   muscles 

stages. 

cept    in    last 
stages. 

of  back. 

Erb's  type  begins  in  late  childhood,  before  puberty,  and 
involves  the  muscles  of  the  shoulder  girdle,  including  the  del- 
toid, the  pelvic  girdle  and  the  back.  Because  of  atrophy  of  the 
muscles  of  the  back,  the  child  stands  with  a  decided  arch  in 
the  back  and  lordosis,  the  shoulder  blades  are  thrown  backward 
and  the  shoulders  forward. 

The  legs  are  affected  late  in  the  disease. 

In  the  pseudohypertrophic  form  the  principal  change  is  in 
the  calf  of  the  legs  and  thighs.  As  the  name  implies,  there  is 
a  decided  increase  in  the  size  of  the  legs  and  thighs,  with  a  coin- 
cident loss  in  power.  The  gait  is  a  peculiar  M^addling  one. 
"When  sitting  on  the  floor  characteristic  positions  are  assumed 


554 


THE  DISEASES  OF   CHILDREN. 


in  attempting  to  get  upon  his  feet.  With  the  assistance  of  his 
hands  he  climbs  up  on  himself,  gradually  assuming  the  erect 
posture,  with  the  lordosis  present,  standing  with  feet  wide  apart. 
When    prostrate    upon    the    floor    he    cannot   rise.     When    the 


Fig.  86. 


Fig.  87. 


Fig.   88. 

Typical    attitudes    assumed    by    patient    with    pseudohypertrophic    muscular    paralysis. 
(Courtesy   Dr.   Frank   L.   Christian,    Elmira,   N.   Y.) 


muscles  of  the  arm  and  forearm  are  involved  the  same  hypertro- 
phy takes  place  here.  Late  in  the  disease  the  face  takes  on  a 
peculiar  lack  of  expression  and  intelligence. 

Prognosis. — As  to  cure,  this  is  grave.  Arrest  of  the  disease 
has  been  reported. 

Treatment. — The  general  tonic  treatment  is  indicated,  with 
massage,  electricity,  hydrotherapy,  attention  to  diet,  etc. 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


555 


DISEASES  OF  THE  MENINGES  AND  BRAIN. 
Meningitis. 

Several  varieties  of  meningitis  are  named,  simpel  acute  men- 
ingitis; tubercular  meningitis;  cerebrospinal  meningitis,  with 
numerous  subdivisions  according  to  the  part  involved  and  the 
etiology. 

Simple  Acute  Meningitis. 

Etiology. — This  form  of  trouble  is  essentially  due  to  an  in- 
fection, either  during  the  infectious  dis- 
eases, typhoid  fever,  pneumonia,  the  exan- 
themata, •  influenza,  nephritis,  etc.,  to 
trauma  or  to  emboli  of  a  septic  nature  and 
middle-ear  trouble.  The  pneumococcus, 
streptococcus,  and  staphylococcus,  typhoid 
and  influenza  bacilli  are  the  organisms  most 
frequently  found. 

Pathology. — The  chief  inflammatory 
changes  are  in  the  pia  mater,  followed  by  a 
change  in  the  dura.  The  greatest  involve- 
ment is  at  the  base,  principally  the  poste- 
rior portion.  The  serous  membrane  is  red, 
thickened,  dull  and  rough,  covered  with 
fibrin ;  this  stage  is  followed  by  one  of  effu- 
sion, at  the  base  or  in  the  ventricles.  This 
may  be  serum,  or  according  to  the  infecting 
organism,  purulent  in  character. 

Symptoms.-A  'short  period  of  indisposi-  ^'f./'enl^Sent.'p^eu: 
tion  mav  be  present,  the  nature  of  which  is  f°''^;Pf.''ir°i!^'*'  ™''^"'" 
not  even  suspected  with  gradual  develop- 
ment of  the  symptoms,  or  it  may  begin  with  a  convulsion,  high 
fever  and  rapid  pulse.  There  may  also  be  severe  headache,  vom- 
iting of  the  projectile  type,  sleeplessness,  restlessness,  photo- 
phobia and  rigidity  of  the  neck.  The  convulsions  may  be  re- 
peated. The  temperature  is  usually  high,  104°  F.,  but  may 
average  101°  F.  or  102°  F.  The  pulse  and  respiration  are  apt 
to  be  irregular.  Coma  or  stupor  may  be  prominent.  Opistho- 
tonos may  occur  shortly  before  death  or  in  one  of  the  con- 
vulsions. 


556  THE  DISEASES  OP    CHILDREN. 

The  duration  is  usually  from  ten  days  to  three  weeks,  or  even 
much  longer. 

Prognosis. — This  is  grave.  Recovery  sometimes  occurs,  but 
the  diagnosis  is  often  questioned  closely  before  admitting  the 
correctness  of  it. 

Diagnosis. — Differential  diagnosis  from  tubercular  and  epi- 
demic cerebrospinal  meningitis  considered  later.  In  the  pres- 
ence of  convulsions  as  the  primary  symptom,  the  diagnosis 
should  not  be  made  until  the  various  intoxications,  as  intestinal, 
etc.,  are  eliminated,  as  they  can  be  usually  in  a  few  days,  at  the 
most.  Lumbar  puncture  will  aid  the  diagnosis  by  examination 
of  the  fluid  removed. 

Treatment. — Absolute  quiet,  in  bed,  in  a  darkened  room. 
Purgation,  preferably  by  calomel  followed  by  a  saline,  is  pos- 
sible, and  the  intermittent  application  of  an  ice  bag  to  the  head, 
at  the  base,  sides  and  top,  is  beneficial.  Hydrotherapy  for  the 
temperature  and  the  administration  of  bromide  and  chloral  for 
the  control  of  the  convulsions  and  restlessness.  Iodides  during 
convalescence  is  helpful. 

Liquid,  perhaps  predigested,  nourishment  and  attention  to 
the  kidneys  is  important. 

EPIDEMIC  CEREBROSPINAL  MENINGITIS. 

Synonym. — Spotted  fetter. 

As  the  name  implies,  this  form  of  meningitis  occurs  epidemic- 
ally, and  is  due  to  the  specific  organism,  the  diplococcus  intra- 
cellularis.  Dr.  J.  Lewis  Smith  wrote  of  the  first  case  having 
occurred  in  the  United  States  in  1806,  since  which  time  epi- 
demics have  occurred  in  all  parts  of  the  country. 

Etiology  and  Bacteriology.— The  specific  organism  causing 
the  disease  is  the  diplococcus  intracellularis  or  the  meningo- 
coccus of  Weichselbaum.  It  is  described  ^  as  of  slight  viability 
on  all  media,  the  best  being  agar,  to  which  has  been  added  sheep 
serum  and  2  per  cent  glucose.  Cultures  were  kept  alive  five  or 
six  days  in  this  media.  It  is  supposed  to  gain  entrance  to  the 
system  through  the  nasal  mucous  membrane  and  through  the 


'Flc.xut'r:   Journal    Auifrifaii    Mt-dii-al    Assoi-ialioii,    vol.    II,    no.    1. 


DISEASES   OP   THE   NERVOUS   SYSTEM.  557 

upper  respiratory  tract  to  the  blood  stream,  or  a  direct  infection 
through  the  lymph  channels. 

Experimenting  with  guinea-pigs,  the  following  conclusions 
were  reached:  (a)  Cultures  freshly  isolated  are  more  virulent; 
(&)   cultures  attenuated  by  artificial  growth  cannot  be  rejuve- 


Fig.  90. — Pure  culture  of  meningococcus,  rfo  liours  old.  Note  the  irregular  stain- 
ing, the  arrangement  in  pairs  of  the  biscuit-shaped  organisms  and  the  ap- 
proximation of  the  flat  surfaces  of  the  individual  bacteria.  Note  that  the  di- 
vision between  the  individual  cocci  cannot  be  determined  in  many  instances. 
(Sophian:      Epidemic   Cerebrospinal   Meningitis.) 

nated  by  passage  through  animals  ;(c)  autolysis  of  an  attenuated 
culture  may  yield  an  extract  which  may  be  used  as  an  adjuvant 
to  increase  the  activity  of  other  cultures;  (d)  quantities  of  cul- 
tures injected  vary  little  in  effect;  (e)  guinea-pigs  respond 
relatively  very  poorly.  The  nasal  mucous  membrane  has  been 
demonstrated  to  be  a  carrier,  and  hence  a  disseminator  of  the 
meningococcus. 

The  fact  that  the  organism  is  present  in  the  naso-pharynx  of 
a  healthy  person  shows  how  the  disease  may  be  transmitted 
1)y  "carriers." 

It  occurs  both  in  adults  and  children,  cases  as  young  as  three 
months  having  been  reported ;  Rotch  ^  reports  one  case  in  an 
infant  24  hours  old. 

Pathology. — The  gross  pathological  changes  are  much  like 
tl  ose  in  other  varieties.  There  is  an  intense  hyperemia  of  the 
meninges  of  brain  and  cord,  which  is  followed  by  an  exudate 


^  Archives   of    Pediatrics,    October,    1908. 


558 


THE  DISEASES  OP   CHILDREN. 


Series  of  Microphotographs   Illustrating  the   Change  in  the 

Cerebrospinal  Fluid  Under  the  Influence  of  Serum 

Treatment  with  Improvement. 


Fig.  91. 


'     Fig.  92. 


Fig.  94. 


Fig.  91. — Stained  sediment  of  cerebrospinal  fluid  removed  from  a  case  of  epidemic 
meningitis  at  the  beginning  of  the  disease,  before  serum  treatment  was  insti- 
tuted.     Note  the  presence  of  intra-  and  extracellular  diplococci  and  pus-cells. 

Fig.  92. — Appearance  of  sediment  24  hours  after  30  cc.  of  serum  had  been  in- 
jected subdurally.  Note  the  marked  diminution  in  the  total  number  of  bacteria 
and  the  fact  that  most  of  them  are  intracellular,  only  a  few  being  extracellular. 
This  condition  was  associated  with  evidence  of  clinical  improvement  in  the 
disease. 

Fig.  93. — Stained  sediment  of  cerebrospinal  fluid  obtained  24  hours  after  the  second 
dose  of  antimeningitis  serum.  Most  of  the  bacteria  have  disappeared,  the  few 
remaining  diplococci  being  intracellular.  The  pus-cells  are  more  numerous, 
probably    as    a    direct   result    of   the   beneficial    action    of    the    serum. 

Fig.  94. — Sediment  of  the  cerebrospinal  fluid  48  hours  after  the  third  dose  of 
serum.  Bacteria  have  totally  disappeared  and  the  cytological  picture  is  chang- 
ing. A  moderate  number  of  lymphocytes  are  beginning  to  appear.  The  patient 
at  this  stage  was  rapidly  recovering.  (Sophian:  Epidemic  Cerebrospinal 
Meningitis. ) 


DISEASES   OF   THE   NERVOUS   SYSTEM.  559 

of  thick  seropus.  The  entire  surface  of  the  brain  and  cord  is 
covered  with  the  exudate,  which  also  extends  in  the  fissures  of 
the  brain,  and  between  the  pia  and  the  cortex,  and  the  ventricles 
may  contain  a  large  amount  of  fluid.  The  meningococcus  is 
found  in  the  cells  and  exudate,  and  larger  numbers  of  poly- 
morphonuclear neutrophiles  than  lymphocytes  are  found.  There 
is  a  high  leucoeytosis. 

Symptoms. — The  onset  is  as  a  rule  abrupt,  but  the  diagnosis 
cannot  be  made  on  the  first  day  of  illness.  Vomiting,  followed 
by  a  chill  or  rigors  and  high  temperature  and  very  often  con- 
vulsions, are  among  the  early  symptoms.  Headache  is  con- 
stant and  often  agonizing;  there  is  pain  in  back  and  neck  and 
early  delirium  is  frequent.  Backward  retraction  of  the  head 
and  back  occur  early  with  rigidity  of  the  neck.  The  vomiting 
at  this  stage  is  projectile  in  character.  The  whole  picture  is  one 
of  an  overwhelming  infection  from  the  beginning.  The  fever 
ranges  between  102°  and  104°  F.,  but  may  go  very  much  higher. 
Reflexes  are  exaggerated. 

A  characteristic  symptom  is  the  development  of  an  eruption 
on  the  body,  hemorrhagic  in  character,  at  first  petechial,  then 
larger  bruise-like  areas.  Herpes  is  found  on  lips  and  face. 
Kernig's  sign  is  usually  present,  also  Babinski's  reflex.  Mace- 
wen's  sign,  or  the  production  of  a  hollow  note  on  percussion 
over  the  parietal  bones  is  not  a  constant  or  easily  obtained  sign. 

Coma  may  develop  early.  Otitis  media  is  sometimes  present 
as  a  result  of  an  early  infection  of  the  middle  ear.  Purulent 
conjunctivitis  is  often  present,  also  corneal,  bulbar  and  con- 
junctival anesthesia.  Maier's^  observation  of  muscle  soreness, 
especially  in  the  lumbar,  erector  spin^e,  thigh  and  upper  arm 
muscles,  is  a  valuable  sign. 

Several  types  are  seen  in  the  same  epidemic,  the  fulminant 
and  rapidly  fatal  cases,  which  die  within  two  or  three  days; 
the  milder  eases,  in  which  the  symptoms  are  not  nearly  so 
severe,  and  those  cases  which  are  very  mild  and  of  short 
duration. 

Prognosis. — This,  under  former  methods  of  treatment,  has 
varied  in  different  epidemics.     IMortality  was  from  25  to   75 


1  Royer:   Archives  of  Pediatrics,   October,    1908. 


560 


THE   DISEASES   OF    CHILDREN. 


Fig.  95. — Boy  of  eleven,  ill  forty-eight  hours  with  epidemic  meningitis.  He  was 
actively  delirious  so  that  he  had  to  be  held  for  the  photograph.  Note  the  pos- 
ture. The  head  uiarkedly  retracted,  back  bowed.  (Sophian:  Epidemic  Cere- 
brospirial  Meningitis. ) 


Fig.    96. — A    boy    of    thirteen    lying    in    the    usual    position    of    those    ill    with    epidemic 
meningitis.      (Courtesy    Dr.    B.    Franklin    Royer,    Philadelphia.) 


Fig.  97.- — Photograph  of  a  boy  ten  and  one-half  years  old,  taken  five  days  after 
the  onset  of  epidemic  meningitis,  showing  opisthotonos.  (Courtesy  Dr.  B. 
Franklin   Royer,    Philadelphia.) 


DISEASES  OF  THE  NERVOUS  SYSTEM.  561 

per  cent,  while  now,  under  the  serum  treatment,  the  recoveries 
have  been  75  per  cent.  Dunn  ^  reports  a  mortality  of  19  per 
cent  in  40  cases  treated  with  the  serum.  Hence  early  diagnosis 
and  treatment  are  very  necessary.  Flexner  -  states  that  so  long 
as  the  diploeoccus  is  still  present  in  the  exudate  from  the  spinal 
canal,  and  the  mechanical  damage  to  the  anatomic  structure  is 
not  irreparable,  the  employment  of  the  serum  holds  out  hope 
of  considerable  benefit.  As  a  result  of  serum  treatment  soon 
after  injection,  the  diplocoeci  tended  to  be  greatly  reduced  in 
numbers,  to  disappear  from  the  fluid  part  of  the  exudate, 
to  become  wholly  intracellular,  to  present  certain  changes  in 
appearance,  as  swelling  and  fragmentation,  and  to  stain  dif- 
fusely and  indistinctly,  and  coincidently  to  lose  viability  in 
culture. 

The  exudate  in  the  meninges  rapidly  loses  turbidity  under 
influence  of  serum  injections. 

Functional  restoration  of  the  meninges  is  certain  even  where 
the  exudate  has  been  purulent.  Unfavorable  indications  after 
several  injections  of  serum  are,  progressive  increase  in  turbidity 
of  exudate,  rise  in  leucocytosis  and  greater  persistence  of  the 
diplocoeci  with  retention  of  viability.  Eelapse  is  attended  or 
ushered  in  by  increased  exudation  of  leucocytes  in  meninges, 
higher  systemic  leucocytosis,  and  reappearance  of  or  increase 
in  the  numbers  of  diplocoeci;  although  they  may  not  regain 
power  to  grow  outside  the  body  in  cultures. 

Relapses  during  treatment  are  not  very  frequent,  and  rarely 
has  a  case  terminated  fatally  during  relapse  when  the  treat- 
ment with  serum  has  been  resumed  without  delay  and  vigor- 
ously pushed.  The  recovery  in  serum-treated  cases  is  in  the 
great  majority  of  instances  complete.  The  number  of  compli- 
cations is  small,  deafness  being  a  persistent  defect. 

Diagnosis. — ^This  is  best  cleared  up  by  use  of  the  lumbar 
puncture  and  examination  of  the  cerebrospinal  fluid  for  the 
specific  organism.  Injection  of  the  fluid  in  guinea-pigs  may  be 
necessary  to  clear  up  the  diagnosis.  The  occurrence  of  a  second 
or  third  case  in  a  vicinity  is  often  sufficient  to  make  the  diagnosis. 

Counting  and  differentiating  the   cells  in  the  cerebrospinal 


1  Archives  of   Pediatrics,    October,    1908.  ^  Loc.   cit. 


562  THE  DISEASES  OP   CHILDREN. 

fluid  is  of  great  assistance.  In  this  type  the  poljinorphonuclear 
cells  predominate  largely;  in  the  tubercular  form  the  predomi- 
nating cells  are  lymphocytes,  and  they  are  few,  and  the  fluid  is 
much  clearer. 

Treatment. — The  serum  treatment  of  this  disease,  with  the 
serum  discovered  by  Flexner,  is  the  only  one  which  offers  any 
hope  of  cure.  Of  393  cases  reported  by  Flexner  there  was  a 
recovery  of  75  per  cent. 

The  signs  of  improvement  in  the  case  are  shown  usually  24 
hours  after  the  injection. 

To  Flexner  is  due  the  credit  of  developing  the  serum  treat- 
ment of  this  disease.  He  describes  the  action  and  administra- 
tion of  the  remedy  as  follows:  The  action  of  the  serum  is  anti- 
toxic and  bacteriolytic,  and  is  brought  into  contact  with  the 
germs  by  injection  into  the  cerebrospinal  canal  after  as  much 
cerebrospinal  fluid  as  possible  has  been  drawn  off. 

The  serum  is  harmless  and  has  brought  about  a  decided 
reduction  in  the  mortality  in  the  disease,  from  80  per  cent  to 
less  than  30  per  cent.  After  the  first  injection  the  number  of 
meningococci  free  in  the  fluid  outside  the  cells  are  decreased, 
after  the  second  or  third  injection  those  in  the  cells  are  de- 
stroyed and  the  amount  of  fluid  is  less.  The  serum  should 
always  be  given  by  the  subdural  injection,  never  subcutaneously. 

Lumbar  puncture  should  be  performed  in  every  suspicious 
case  at  once,  and  if  the  fluid  is  turbid  20  to  30  ec.  of  warmed 
serum  injected.  The  fluid  \vithdrawn  must  be  examined  for 
the  organism,  and  if  found  the  injection  repeated  daily  until 
symptoms  are  improved.  Forty-five  cubic  centimeters  are 
recommended  as  the  maximum  dose  of  the  senira,  governed 
somewhat  by  the  amount  of  resistance  to  the  serum  as  it  is 
injected.  Doses  of  30  cc.  are  necessary  for  good  results.  The 
dose  should  be  repeated  daily  as  long  as  diplocoeci  are  found  in 
the  spinal  fluid.  At  least  four  daily  doses  should  be  given, 
even  if  the  diplocoeci  disappear  earlier.  In  fulminant  eases 
the  injection  can  be  given  oftener  than  once  in  24  hours.  R^ 
appearance  of  diplocoeci  is  indication  for  repeating  injections. 

As  a  result  of  the  injections  the  temperature  drops  in  from 
3  to  12  hours,  and  the  other  symptoms  improve,  especially  the 


DISEASES   OP   THE   NERVOUS   SYSTEM,  563 

headache  and  delirium;  pain  and  hyperesthesia  are  relieved, 
coma  is  lessened,  intelligence  slowly  returns  and  nourishment 
is  taken.  The  strabismus  and  Kernig's  sign  are  more  persist- 
ent. The  polymorphonuclear  leucocytes  in  the  fluid  increase 
in  number  after  the  first  injection. 

The  question  of  control  of  epidemics  is  a  most  important  one. 
In  cities  and  towns  in  which  an  epidemic  exists,  strict  quarantine 
of  all  cases  should  be  maintained,  and  the  nasopahryngeal  secre- 
tion of  recovered  cases  carefully  examined  bacteriologically. 
JNInnieipalities  can  well  afford  the  furnishing  of  the  serum  gratis. 

The  General  Treatment. — The  patient  should  have  most  care- 
ful nursing.  If  very  violent  attendants  must  be  provided  to 
prevent  the  patient  from  doing  himself  an  injury.  Gavage  and 
nasal  feeding  may  have  to  be  resorted  to  in  those  profoundly 
unconscious.  Ice  applied  to  the  head  and  neck  allays  much  of 
the  restlessness.  Free  purgation  should  be  maintained.  Hydro- 
therapy for  hyperpyrexia  is  of  service. 

ACUTE  ENCEPHALITIS. 

This  is  an  inflammation  of  the  brain  tissue  itself. 

Etiology. — Any  of  the  acute  infectious  or  contagious  dis- 
eases may  be  the  exciting  cause  of  this  condition.  Influenza, 
the  exanthemata,  diphtheria,  pertussis,  pneumonia,  erysipelas, 
ulcerative  endocarditis,  the  acute  septic  diseases  and  meningitis 
may  be  causes. 

Pathology. — The  primary  condition  is  hemorrhagic,  the  in- 
flammatory areas  surrounding  these  spots,  round-cell  infiltra- 
tion and  degeneration  take  place. 

Symptoms. — It  occurs  in  young  children  and  is  preceded  by 
a  short  period  of  depression,  restlessness  and  headache  followed 
by  great  drowsiness  or  by  coma.  Convulsions  may  precede- 
the  active  symptoms.  There  is  fever  up  to  104°  F.  or  105°  F., 
rapid  and  irregular  pulse;  shallow,  hurried  breathing,  which 
becomes  irregular  or  Cheyne-Stokes,  as  the  disease  progresses. 

Motor  and  sensory  symptoms  develop  according  to  the  area 
most  involved.  Rigidity  of  the  neck  is  present  early,  paralysis 
or  hemiplegia  may  present,  ocular  palsies  often  develop ;  deaf- 
ness is  usually  i)resent  early,  and  if  recovery  takes  place  the 
hearing  is  not  reestablished. 


564  THE  DISEASES   OF   CHILDREN. 

Prognosis. — This  is  very  grave,  but  varies  according  to  the 
extent  of  involvement  of  the  brain.  If  some  remission  in  the 
symptoms  is  noted  by  the  end  of  the  first  week  the  prognosis 
is  more  favorable. 

Treatment. — Absolute  rest;  calomel  purgation,  ice  to  head 
and  spine,  and  a  blister  to  the  cervical  region  of  the  spine. 
Supportive  and  sedative  treatment  may  be  indicated  at  differ- 
ent times. 

HYDROCEPHALUS. 

This  is  an  accumulation  of  cerebrospinal  fluid  either  in  the 
subdural  spaces  or  in  the  ventricles.  It  may  be  congenital  or 
acquired,  primary  or  secondary,  acute  or  chronic. 

ACUTE  HYDROCEPHALUS. 

Etiology. — Trauma  may  be  a  factor,  and  it  probably  is  of 
microbic  origin,  though  nothing  definite  is  known  of  its  cause. 
It  may  be  due  to  tuberculosis  or  syphilis.  A  condition  known 
as  meningitis  serosa  may  exist,  following  trauma  or  infectious 
diseases. 

Pathology. — Inflammation  of  the  brain  or  meninges,  venous 
or  lymphatic  stasis  may  be  present.  The  accumulation  of  fluid 
in  the  ventricles  may  continue  and  be  so  great  as  to  cause  thin- 
ning of  the  brain  from  internal  pressure. 

Symptoms. — Slight  fever  may  usher  in  the  condition,  con- 
tinuing a  few  days  and  gradually  subsiding,  with  perhaps  a  rise 
at  a  later  date.  Headache  is  one  of  the  earliest  of  the  sub- 
jective symptoms,  associated  with  retraction  of  the  neck,  and 
probably  opisthotonos.  Bulging  of  the  fontanelles  takes  place. 
Headache,  blindness,  stupor  and  coma  may  be  present.  As  the 
fever  drops  to  normal  all  of  these  symptoms  may  be  relieved 
for  a  short  period,  and  again  come  on  as  the  temperature  rises. 
There  may  be  no  improvement,  the  child  succumbs  to  intracranial 
pressure.  The  opposite  may  obtain,  the  symptoms  growing  less 
in  severity  and  the  child  finally  recovering.  Symptoms  are 
sometimes  relieved  by  lumbar  puncture,  nothing  abnormal  being 
found  in  the  fluid. 

Prognosis. — This  depends  largely  upon  the  cause  of  the  con- 
dition and  its  severity.     Cases  do  recover  in  which  the  diagnosis 


DISEASES   OP   THE   NERVOUS   SYSTEM.  565 

is  positive.  Recovery  or  amelioration  of  all  symptoms  but  the 
blindness  may  occur.  In  general  the  prognosis  is  unfavorable. 
Treatment. — Lumbar  puncture  is  indicated  and  should  be 
repeated  if  the  effects  of  the  first  have  been  good.  This  treat- 
ment gives  the  only  hope  of  cure,  as  no  medication  is  of  avail. 

CHRONIC  HYDROCEPHALUS. 

The  typical  form  of  this  variety  is  the  congenital  type,  though 
a  further  subdivision  is  made  by  some  authorities. 

Etiology. — The  cause  of  the  congenital  form  is  not  known. 
I  delivered  a  dead  child  at  term  with  an  enormous  hydro- 
cephalus, in  which  the  cord  was  wrapped  tightly  around  the  neck 
three  times,  enough  pressure  being  exerted  to  make  a  deep 
groove  in  the  neck  in  which  the  coils  of  cord  rested. 

It  occurs  where  both  parents  are  perfectly  healthy,  and  not 
infrequently  it  is  the  first-born  so  affected,  and  later  children 
are  perfectly  normal.  Mother  and  daughter  have  been  known 
to  have  a  hydrocephalic  first-born.  Syphilis,  alcoholism,  tuber- 
culosis in  the  parents  have  been  given  as  causes. 

In  this  form  the  head  is  enlarged  at  birth  and  may  be  the 
cause  of  dystocia.  It  continues  to  enlarge  after  birth.  Not 
infrequently  associated  with  the  hydrocephalus  is  an  imperfect 
closure  of  the  spinal  canal,  spina  bifida,  or  one  of  the  varieties 
of  talipes. 

Enormous  accumulation  of  fluid  may  take  place  in  the  ven- 
tricles, distending  them  and  compressing  the  brain  until  it  is 
greatly  attenuated. 

The  sutures  are  widely  separated,  especially  the  frontal, 
coronal  and  sagittal,  and  the  fontanelles  are  very  large  and 
bulging. 

Symptoms. — The  first  thing  noticed  in  these  infants  is  the 
very  high,  bulging  forehead,  with  an  upward  tilting  of  the 
eyes  and  a  tendency  to  exophthalmos.  As  the  fluid  increases  a 
nystagmus  is  apt  to  begin.  There  may  be  a  stationary  period  in 
which  the  head  does  not  enlarge,  and  the  child  may  be  able  to 
hold  it  up  without  special  support,  but  as  the  fluid  increases 
in  amount  the  head  cannot  be  raised  from  the  pillow  or  turned. 

It   is   often   surprising   the   amount   of   intellection   exhibited 


566 


THE   DISEASES   OF    CHILDREN. 


in  these  cases,  which  at  autopsy  show  such  thinning  of  brain 
tissue. 


Fig.   98. — Hydrocephalus.      Child   six  years   old. 


Fig.   99. — Side   view   same   child. 

The  following  hi,story  of  child  whose  pictures  are  shown  is  of  interest. 
Female,  colored,  6  years  old.  Third  child,  others  normal.  Had  a  con- 
vulsion when  12  days  old.  Head  began  enlarging  at  6  weeks.  At  3  weeks 
had  bronchitis;  2  years  of  age  measles;  3  years  whooping-cough.  Cut  first 
tooth  at  one  year  of  age.  Circumference  of  head  32i  inches,  from  occipital 
protuberance  to  bridge  of  nose  29  inches.     This  child  died  when  6J  years  old. 

A  ease  which  was  under  my  observation  when  an  interne  at 
the  New  York  Infant  Asylum  was  admitted  during  the  service 
of  Dr.  L.  Emmet  Holt,  and  through  whose  courtesy  the  case 
was  reported  in  the  American  Practitioner  and  News,  January 
2,  1892. 

She  was  the  fourth  child  of  healthy,  German  parentage;  head  large  and 
soft,  with  bulging  fontanelles  at  birth.  At  the  age  of  one  month  the  head 
measured  19  inches  in  circumference,  and  while  under  observation  the  gain 
in  circumference  was  at  the  rate  of  half  an  inch  a  week. 


DISEASES   OF   THE   NERVOUS   SYSTEM.  567 

There  was  a  divergent  strabismus,  axis  of  eyes  turned  upward,  pupils  ac- 
tive and  followed  light;  no  contractures,  rigidities  or  convulsions. 

The  child  died  at  the  age  of  four  months,  and  the  head  was  24J  inches 
in  circumference,  16  inches  from  ear  tip  to  tip,  and  from  occipital  pro- 
tul)erance  to  bridge  of  nose,  20  inches.  Eighty-eight  ounces  of  fluid  were 
withdrawn  by  a  trocar.  The  brain  in  its  thickest  portion  at  the  base 
varied  from  ^  to  ^  inch  in  thickness.  There  was  free  communication  be- 
tween the  lateral  ventricles  and  the  third  ventricle  at  the  base.  The 
medulla,  pons  and  cerebellum  appeared  normal.  There  was  no  evidence  of 
meningitis  or  tumor. 

Diagnosis. — This  must  be  made  from  rachitis,  and  should  be 
easy.  The  enlargement  of  bone  at  the  centers  of  ossification, 
the  other  bony  changes,  headsweats,  etc.,  make  the  diagnosis  of 
rachitis  easy. 

Prognosis. — This  is  always  serious  and  a  guarded  opinion 
should  be  given,  even  where  there  is  an  apparent  improvement 
in  intellection  and  no  progressive  enlargement  of  the  head. 

Treatment. — This  is  entirely  symptomatic  and  palliative  as  no 
medicine  which  may  be  given  can  cause  an  absorption  of  the 
fluid. 

Drainage  of  the  fluid  by  tapping  the  ventricles  through  the 
fontanelles  or  by  lumbar  puncture  may  prove  efficacious  in  some 
cases,  and  should  be  repeated  if  found  so. 

CEREBRAL  PALSIES  OF  CHILDHOOD. 

Synonyms. — Spastic  hemiplegia;  spastic  paraplegia  or  dip- 
legia. 

Etiology. — The  most  frecjuent  and  potent  factor  in  the  cause 
of  these  conditions  is  a  much-delayed  labor,  in  the  first-born, 
very  often,  and  the  injudicious  or  faulty  use  of  the  obstetrical 
forceps.  Asphyxia  at  the  time  of  birth  may  play  a  part  in  its 
causation.  Injury  to  the  mother  during  the  last  weeks  of  gesta- 
tion may  be  a  cause.  Hemorrhages  in  the  brain  or  brain  in- 
juries are  the  active  causes. 

Heredity  should  be  considered.  There  may  be  a  distinct 
history  of  similar  children  affected  in  the  parents'  family. 

The  acute  exanthemata  may  act  as  a  cause  of  the  acute  palsies. 
Trauma  after  birth  may  also  act  as  a  cause.  Convulsions  and 
whooping-cough  may  give  rise  to  pathologic  conditions  in  the 
brain  which  would  result  in  spastic  paralysis. 


568  THE  DISEASES  OP   CHILDREN. 

Pathology. — In  those  cases  being  present  at  birth,  more  severe 
lesions  are  generally  found,  as  a  porencephaly,  defective  devel- 
opment of  the  brain  or  parts  of  it;  meningeal  hemorrhages; 
cysts;  thrombosis  or  embolism,  meningitis  or  encephalitis,  scler- 
osis, hydrocephalus,  and  failure  of  development  of  the  cortical 
cells. 

Symptoms. — Usually  three  types  are  described,  according  to 
the  body  area  involved,  viz. :  Cerebral  spastic  hemiplegia;  spastic 
paraplegia. 

The  symptoms  vary  according  to  the  time  of  development,  the 
situation  and  extent  of  the  brain  involvement.  If  it  occurs  di- 
rectly after  birth  there  may  be  convulsions,  coma  and  cyanosis. 
In  those  developing  later,  convulsions  mark  the  onset.  ]\Iany 
cases  appear  during  the  first  year  of  life,  and  fully  two-thirds, 
perhaps  more,  begin  in  the  first  three  years  of  life.  Convul- 
sions may  recur  at  fairly  regular  intervals  for  some  time  after 
their  onset. 

When  of  the  leg,  there  is  a  decided  limp  and  spastic  gait.  Some 
contracture  is  nearly  always  present.  Athetoid  and  choreiform 
movements  may  be  seen  of  the  affected  muscles. 

The  paralyses  are  at  first  flaccid,  but  they  rapidly  become 
spastic,  the  paralyzed  side  remains  smaller  and  undeveloped. 
Idiocy  is  one  of  the  important  sequels,  it  may  develop  in  a  short 
while  after  the  onset  of  the  trouble. 

In  qnadriplegia  all  four  extremities  are  involved,  extensive  in- 
jury to  the  brain  probably  having  taken  place.  All  of  the  symp- 
toms in  a  hemiplegia  are  present  in  this  form,  only  more 
severe. 

In  paraplegia  only  the  lower  extremities  are  involved,  and  the 
lesion  is  very  apt  to  be  at  the  apex  of  the  brain. 

Diagnosis. — The  spastic  character  of  the  paralysis,  the  di- 
minished intelligence,  age  of  patient  and  history  of  the  onset  is 
usually  sufficient  to  make  a  diagnosis.  Reflexes  are  nornuil  or 
exaggerated  in  contradistinction  to  otlicr  siniihir  conditions  hav- 
ing no  reflexes. 

Prognosis. — This  is  unfavorable,  but  cases  do  show  an  im- 
provement when  the  severe  form  of  paralysis  was  present  early. 
The  early  development  of  failing  intellection  is  grave.     Repeated 


DISEASES   OF   THE   NERVOUS   SYSTEM.  569 

convulsions  make  the  outlook  bad.  If  no  improvement  takes 
place  in  the  contractures,  the  prognosis  is  not  so  good. 

Treatment. — Prophylaxis  is  most  important.  Intelligent 
care  of  all  labors,  intelligent  interference  when  indicated,  ef- 
fectually prevent  injuries  occurring  during  childbirth.  Owing 
to  the  idiocy,  these  cases  do  best  where  they  are  under  constant 
surveillance,  hence  the  importance  of  confining  them  at  a  public 
institution,  if  possible. 

Proper  hygiene,  diet  and  general  supervision  of  the  life  of 
the  child  is  necessary.  Orthopedic  surgery  is  indicated  always, 
where  large  amount  contractures  are  present. 

TUMORS  OF  THE  BRAIN  AND  MENINGES. 

Tumors  of  the  brain  are  comparatively  frequent  in  childhood. 
Peterson  has  reported  335  cases  as  follows : 

TABLE  I. 

Form  of  Tumor.  No.  of  Cases. 

Tubercle     166 

Glioma     42 

Sarcoma     37 

Cyst    35 

Carcinoma     11 

Gliosarcoma    5 

Angiosarcoma     1 

Myxosarcoma    1 

Papillary  epithelioma    1 

Gumma     1 

Not  stated    35 

Total 335 

TABLE  II. 

Site  of  Tumor.  No.  of  Cases. 

Cerebellum    105 

Pons   Varolii    42 

Centrum  ovale    41 

Basal  ganglia  and  lateral  ventricles    30 

Corpora  quadrigeniina  and  crura  cerel)ri    25 

Cortex  cerebri    23 

TMcdulla   oblongata    7 

Fourth   ventricle    6 

Base   of  brain    8 

Total    287 


570  THE   DISEASES  OP    CHILDREN. 

Tubercular  tumors  are  more  often  met  than  any  other  variety, 
and  they  are  found  most  frequently  in  the  cerebellum. 

Etiology. — With  the  exception  perhaps  of  gliomata,  tumors 
of  the  brain  are  secondary  to  growths  of  like  character  else- 
where in  the  body.  A  glioma  may  result  from  an  injury  or 
blow. 

Pathology. — The  tubercle  may  occasion  a  variety  of  growths 
and  affect  any  part  of  the  nervous  system.  It  occurs  as  a  soli- 
tary tubercle  or  as  multiple  tumors,  and  tuberculosis  in  other 
parts  of  the  body,  as  the  bronchial  glands,  lung,  mesentery,  etc., 
is  the  starting  point  of  the  infection.  They  vary  in  size  very 
much,  from  a  pea  to  a  growth  which  occupies  a  greater  portion 
of  the  brain.  These  tumors  are  as  a  rule  encapsulated,  and  may 
on  section  show  softened  areas  in  the  center.  Bacilli  may  be 
demonstrated,  and  in  this  way  they  are  differentiated  from  other 
varieties  of  tumor. 

Glioma  is  a  growth  which  is  found  beneath  the  gray  matter 
in  the  white  matter,  as  a  rule,  though  it  may  involve  the  former 
also.  It  is  a  slower  growth  than  the  others.  An  increase  in  the 
blood  supply  is  present  in  the  areas  involved  in  this  growth.  The 
mass  is  not  encapsulated,  and  is  much  softer  than  the  surround- 
ing tissue. 

Cysts  are  quite  frequently  encountered — found  in  brains  when 
least  expected.  The  origin  of  these  cysts  was  evidently  a  hemor- 
rhagic or  other  process  occurring  in  infancy. 

Gumma  may  occur  in  hereditary  syphilis,  but  is  rare. 

Symptoms. — These  may  be  considered  from  the  standpoint 
of  the  intracranial  pressure  and  cerebral  localization  of  the 
growth. 

"We  believe  that  these  growths  are  very  frequently  not  diag- 
nosed on  account  of  the  vagueness  and  indefiniteness  of  the 
symptoms.  They  vary  greatly  according  to  the  rapidity  of  the 
growth,  the  amount  of  intracranial  pressure  from  it,  coincident 
increased  blood  supply,  and  hydrocephalus  which  follows. 
Among  the  general  symptoms  may  be  mentioned : 
Headache. — This  may  be  the  most  striking  symptom,  both  as 
to  its  severity  and  persistence.  The  pain  is  boring  or  knifelike 
and  causes  restlessness,  photophobia  and  the  typical  cephalic  cry. 


DISEASES   OF   THE   NERVOUS   SYSTEM.  571 

If  the  meninges  are  involved  it  will  be  more  severe  and  localized, 
perhaps  associated  with  tenderness. 

Nausea  and  vomiting,  in  connection  with  a  more  or  less  contin- 
uous headache,  in  a  child  is  a  suspicious  occurrence.  The  vom- 
iting, if  projectile,  is  quite  characteristic  of  brain  invo-lvement, 
and  later  it  occurs  without  nausea  and  irrespective  of  food. 

Convulsions,  in  connection  with  headaches,  are  suspicious,  and 
especially  so  if  the  projectile  vomiting  is  also  present. 

Vertigo  and  dizziness  are  quite  commonly  present. 

Optic  ■  neuritis,  from  the  intracranial  pressure,  is  an  early 
symptom,  perhaps  preceded  for  a  short  time  by  choked  disc. 
Blindness  is  not  uncommon.  Only  one  side  may  be  involved, 
usually  it  is  double.  A  careful  ophthalmoscopic  examination  of 
the  eyes  should  be  made  in  all  suspicious  eases. 

The  pulse  at  the  end  becomes  rapid  and  weak,  and  not  infre- 
quently the  respirations  show  the  typical  Cheyne-Stokes'  type. 

Localization  Symptoms. — This  is  a  special  study  in  itself, 
and  the  reader  is  referred  to  any  late  text-book  on  nervous  and 
mental  diseases  for  a  detailed  description  of  these  diagnostic 
methods. 

Diagnosis. — From  al)scess  by  the  presence  of  fever,  and  pos- 
sibly sweats  in  the  latter.  Abscess  also  forms  more  quickly,  and 
previous  history,  perhaps  of  middle  ear  or  frontal  sinus  disease, 
which  are  suggestive. 

In  tuherciilar  meningitis  which  is  prolonged  the  diagnosis 
may  be  difficult.  Headache  is  usually  more  severe  in  meningitis. 
Lumbar  puncture  is  of  assistance  in  making  a  diagnosis. 

Prognosis. — This   is   extremely   grave   no    matter  what   the. 
character  of  the  growth,  and  even  if  diagnosed  surgery  offers 
very  little  hope  of  cure.     Gummata,  one  of  the  least  frequent 
forms  of  growth,  may  yield  to  specific  treatment. 

Treatment. — Surgery  is  practically  the  only  form  of  treat- 
ment which  offers  any  hope  of  relief,  and  the  outlook  is  exceed- 
ingly grave;  even  with  skilled  surgery  children  bear  operative 
measures  on  the  brain  badly.  The  coal-tar  products,  with  caf- 
feine and  codeine,  may  have  to  be  tried  for  the  relief  of  the 
headaches.  The  bromides  and  chloral  are  of  service  in  certain 
cases,  and  the  regulation  of  the  diet  most  essential. 


572  THE  DISEASES  OP   CHILDREN. 

Because  of  the  disseminated  form  of  the  growth  of  glioma 
and  sarcoma,  operations  for  their  removal  are  not  as  successful 
as  in  other  forms. 

ABSCESS  OF  THE  BRAIN. 

A  much  more  frequent  condition  in  children  than  in  adults. 

Etiology. — The  most  frequent  cause  is  a  preceding  middle- 
ear  or  mastoid  suppuration.  Trauma  is  also  a  frequent  cause, 
and  disease  of  the  nose  and  frontal  sinuses  also.  Abscess  of  the 
brain  follows  venous  infection  and  lateral  sinus  involvement  in 
middle-ear  disease  most  frequently. 

Pathology. — Rarely,  small,  w^alled-off  collections  of  pus  may 
be  found  postmortem  which  were  not  previously  suspected. 
Larger  collections  of  pus  may  be  walled  off,  others  show  no 
distinct  limiting  membrane.  It  may  be  located  in  any  part  of 
the  brain,  beneath  the  dura  or  external  to  it  entirely.  A  num- 
ber of  the  pus-producing  organisms  may  be  found  in  the  pus 
from  these  abscesses.  They  occur  most  often,  perhaps,  in  the 
frontal  and  temperosphenoidal  lobes. 

Symptoms. — Abscesses  located  deep  in  the  brain  tissue  may 
cause  no  symptoms  unless  they  are  large  enough  to  give  symp- 
toms of  intracranial  pressure.  They  are  difficult  of  diagnosis. 
Following  operations  on  the  middle  ear  or  mastoid,  the  diag- 
nosis is  much  easier.  Headache,  vomiting,  irregular  fever  and 
rigors,  drowsiness,  coma  or  convulsions  are  a  train  of  symptoms 
which  are  convincing.  Cerebral  localization,  as  in  brain  tumors, 
must  be  brought  into  consideration  if  the  site  of  the  abscess  is 
to  be  diagnosed. 

Diagnosis. — If  a  history  of  previous  inflammations  contigu- 
ous to  the  brain  is  obtainable,  the  diagnosis  is  easier. 

From  solid  tumors,  the  presence  of  rigors  and  irregular  tem- 
perature is  a  diagnostic  sign. 

In  meningitis  and  inflammation  of  the  lateral  sinus,  the  onset 
is  much  more  sudden  and  tlie  range  of  temperature  higher.  In 
meningitis,  in  addition,  there  is  apt  to  be  retraction  of  the  head 
and  rigidity  of  the  neck. 

An  important  diagnostic  aid  is  a  differential  blood  current. 

Prognosis. — This  is  extremely  grave.     It  is  influenced  by  the 


DISEASES   OF   THE   NERVOUS   SYSTEM.  573 

location,  size  and  duration  of  the  abscess,  and  its  accessibility 
for  surgical  intervention. 

Treatment. — Prophylaxis  is  of  importance  in  ear  and  nasal 
disease,  especially  of  suppurating  variety.  Prevention  of  ex- 
tensive involvement  in  middle-ear  abscess  by  early  paracentesis 
is  indicated  in  all  cases.  Free  and  radical  operation  in  mastoid 
abscess  is  the  best  treatment. 

Brain  abscess  can  be  treated  successfully  only  by  surgery,  and 
careful  exploratory  operation. 

INTRACRANIAL  HEMORRHAGE. 

Hemorrhage  within  the  skull  of  the  new-born  may  be  sub- 
dural, or  within  the  brain  substance,  cerebral. 

Etiology. — This  may  be  due  to  the  general  hemorrhagic 
diathesis  or  disease,  or  if  it  is  present  at  birth  due  to  causes  ex- 
isting during  labor,  either  long-continued  pressure  during  the 
second  stage,  trauma  of  forceps  delivery,  or  forcible  extraction 
of  the  after-coming  head  in  breech  presentations. 

Symptoms. — A  large  hemorrhage,  subdural  in  character, 
may  be  present  at  birth  or  occur  shortly  after,  in  which  event  the 
child  is  either  still-born  or  asphyxiated.  A  hemorrhage  is  the 
most  frequent  cause  of  convulsions  in  the  new-born.  These  are 
more  often  localized  and  not  general.  A  hemorrhage  of  sufficient 
size  to  cause  general  convulsions  is  usually  enough  to  cause  the 
death  of  the  child.  If  the  hemorrhage  is  slow  the  pressure  symp- 
toms will  not  be  so  severe  and  the  child  may  live  some  time,  and 
a  condition  of  cerebral  atrophy  will  develop. 

Cerebral  hemorrhage  is  more  often  seen  in  older  children,  and 
may  occur  as  a  complication  of  the  infectious  diseases.  The  hem- 
orrhage causes  a  period  of  sudden  unconsciousness,  followed  by  a 
paralysis  more  or  less  extensive,  according  to  the  area  involved 
by  the  compression.     Recovery  may  take  place,  but  rarely. 

Prognosis. — In  subdural  hemorrhage,  if  the  primary  as- 
phyxia is  relieved,  the  child  may  recover,  to  be  afflicted  with  one 
of  the  cerebral  palsies  later. 

Treatment. — Artificial  respiration  is  used  to  overcome  the 
primary  asphyxia.  Great  discretion  should  always  be  used  in 
labor  as  to  when  interference  is  justifiable,  to  intelligently  choose 


574  '  THE  DISEASES   OP    CHILDREN. 

between  the  evils  resulting  from  prolonged  labor  and  those  which 
follow  instrumental  delivery.  In  competent  hands  forceps  will 
prevent  trouble  far  more  frequently  than  they  will  do  harm. 

After  the  occurrence  of  the  hemorrhage  but  little  can  be  done, 
medically  or  surgically. 


CHAPTER  XXIII. 

DISEASES  OF  THE  SKIN. 

Owing  to  the  very  delicate  structure  of  the  skin  in  childhood 
many  skin  diseases  at  that  period  are  different  from  those  seen 
in  adults.  At  this  age  the  skin  is  much  more  susceptible  to 
effects  of  irritants,  and  a  number  of  lesions  may  result  from 
mechanical  causes,  heat  or  cold,  light,  medication,  etc. 

INTERTRIGO. 

This  is  a  very  eommon  condition,  and  is  a  chafing  or  rubbing 
off  of  the  superficial  skin,  which  has  been  previously  macerated. 
Its  most  frequent  site  is  the  buttocks,  in  folds  between  the  but- 
tocks, in  the  groins,  and  the  scrotum.  The  chief  cause  is  the 
practice  of  drying  the  napkins  several  times  before  washing 
them,  or  neglect  in  removal  of  fecal  discharges. 

The  primary  lesion  is  an  erythema,  with  deep  congestion  of 
the  skin.  Maceration  takes  place,  and  a  superficial  layer  of  epi- 
dermis is  rubbed  off.  This  leaves  a  moist,  red  surface,  which, 
if  an  infection  takes  place,  becomes  inflamed,  covered  with  pus 
and  encrustations. 

Treatment. — Prophylaxis  is  most  important.  Intertrigo  is 
generally  an  indication  of  carelessness  on  the  part  of  the  nurse. 
Napkins  should  be  properly  cared  for,  boiled  daily,  without 
strong  alkaline  washing  powders.  Soap  should  not  be  used  on 
the  skin  of  the  buttocks  frequently.  A  soft  cloth  and  warm 
water  should  be  used  after  evacuations,  followed  by  a  drying 
powder. 

When  the  first  symptoms  develop  all  digestive  disturbances 
should  be  corrected,  that  the  discharges  may  be  as  unirritating 
as  possible  and  the  urine  examined  for  hyperacidity.  The  nap- 
kin should  be  changed  immediately  it  is  wet  or  soiled,  both  day 

575 


576  THE  DISEASES  OP   CHILDREN. 

and  night,  and  should  not  be  used  again  without  having  been 
washed. 

Stearate  of  zinc  powder  applied  to  the  affected  area  as  soon 
as  cleansed  and  dried  will  frequently  correct  the  condition 
promptly.  If  much  thickening  and  congestion  of  the  skin  is 
present,  Lassar's  paste  will  be  found  efficient. 

SUDAMINA,  MILIARIA. 

This  eruption,  usually  called  "heat"  is  characterized  by  mi- 
nute papules,  which  are  surmounted  by  transparent  vesicles,  due 
to  the  collection  of  sweat  under  the  epidermis.  Some  erythema 
is  seen  between  the  patches. 

Associated  with  this  rash  is  usually  considerable  itching,  the 
child  scratching  even  in  its  sleep. 

The  eruption  is  general,  but  chiefly  located  on  the  chest,  neck 
and  back. 

The  vesicles  rupture  leaving  a  roughened  surface,  followed  by 
a  fine,  scaly  or  branny  desquamation. 

Treatment. — Cool  sponging,  followed  by  drying  with  a  soft 
cloth  and  free  use  of  talcum  powder,  gives  comfort  and  relief 
from  the  itching  and  assists  in  drying  up  of  the  vesicles. 

PARASITIC  SKIN  LESIONS. 
PEDICULOSIS. 

This  is  an  infection  of  the  hair  of  the  body  with  animal  para- 
sites, affecting  the  hair  of  the  head,  and  in  older  children  the 
hair  of  the  pubes  and  body. 

PEDICULOSIS  CAPITIS. 

This  form  is  due  to  the  invasion  of  the  hair  of  the  head  by  the 
parasite  pediculus  capitis. 

The  headlouse  is  grayish  in  color,  1  to  3  mm.  in  length,  oval 
in  shape,  with  six  legs,  containing  claws  arising  from  the  anterior 
portion.  One  female  is  capable  of  laying  about  50  eggs,  which 
hatch  in  about  a  week,  and  the  new  parasites  are  capable  of  re- 
production in  about  three  weeks.  The  eggs  or  nits  are  at- 
tached to  the  side  of  the  hair  one-fourth  to  one-half  an  inch  from 


DISEASES   OF   THE   SKIN,  577 

the  scalp,  usually  two  or  three  to  a  hair,  and  can  be  easily  seen 
by  the  naked  eye.  The  occipital  and  temporal  regions  are  more 
thickly  contaminated  than  the  rest  of  the  head. 

Pediculi  obtain  nourishment  by  sucking  blood  from  the  scalp, 
this  causes  severe  itching,  resulting  in  scratching,  with  abra- 
sions and  infections  of  the  skin,  a  variety  of  exudations  forming 
on  it.  If  many  of  these  are  present  the  postcervical  and  sub- 
maxillary glands  may  become  enlarged  from  absorption  of  pus. 
With  large  encrustations  and  matting  of  the  hair  there  is  a 
very  disagreeable  odor  to  the  head. 

Diagnosis. — Examination  of  the  head  should  always  be  made 
where  great  itching  is  present.  The  nits  can  easily  be  found, 
and  usually  a  parasite,  especially  if  a  fine  tooth  comb  is  run 
through  the  hair.  A  pustular  encrustation  on  the  scalp  and 
neck  is  a  suspicious  occurrence. 

Treatment. — Both  the  pediculi  and  the  ova  must  be  destroyed. 
If  in  a  girl  with  long  hair  and  the  infection  is  very  great,  a  cure 
will  be  much  more  rapid  b}'  cutting  the  hair  or  boxing  it.  In 
a  boy  this  can  be  easily  done.  The  use  of  the  fine  tooth  comb 
is  necessary. 

A  number  of  remedies  have  been  advocated,  none,  however, 
infallible. 

The  head  should  be  washed  with  green  soap  and  the  follow- 
ing applied : 

IJ  Kerosene  oil 

01.  olivse  aa  ^iv 

M.  Sig. :  Applied  to  the  hair  and  thoroughly  rubbed  in,  the  head  tied 
up  in  a  towel  and  allowed  to  remain  over  night. 

The  hair  is  shampooed  the  next  morning  with  green  soap, 
and  this  treatment  repeated  each  night  for  three  nights. 

Tincture  of  coculus  indicus,  diluted  one-third,  can  be  applied 
in  the  same  w^ay;  also  bichloride  of  mercury,  gr.  i  to  the  ounce 
of  water.  To  soften  and  remove  the  ova  a  solution  of  bicarbon- 
ate of  soda  or  of  dilute  acetic  acid  can  be  used  to  advantage. 

PEDICULOSIS  CORPORIS. 

This  is  due  to  the  pediculosis  corporis,  a  louse  larger  than  the 
headlouse.     It  reproduces  itself  in  the  underclothing,  the  ova 


578  THE  DISEASES   OP   CHILDREN. 

being  deposited  in  the  seams  and  folds,  and  hatching  in  about  a 
week. 

The  parasite  fixes  itself  upon  the  skin  and  sucks  blood  there- 
from, this  causing  great  itching.  The  scratching  is  severe,  both 
day  and  night,  which  is  evidenced  by  the  excoriations  on  the 
body  wherever  the  finger  nails  can  reach.  The  site  of  severest 
itching  is  where  the  clothes  fit  the  body  closest,  as  the  waist, 
shoulders,  across  the  back,  etc.  An  inspection  of  the  body  may 
not  reveal  the  parasites,  but  they  are  found  on  the  underclothes. 

This  form  of  louse  is  rarely  seen  in  infancy,  and  is  uncom- 
mon in  children  of  any  age.  It  is  found  chiefly  among  the  poor 
and  uncleanly,  but  rarely  among  negroes. 

The  diagnosis  is  chiefly  to  be  made  from  scabies. 

The  treatment  cannot  be  successful  without  careful  disinfec- 
tion of  the  clothing  and  daily  change  of  the  underclothes. 
Thorough  soaking  of  the  underclothes  in  a  1/20  carbolic  acid 
solution,  followed  by  boiling,  is  suflficient  to  sterilize  them. 

The  itching  can  be  relieved  by  the  use  over  the  body  of  a  5 
per  cent  carbolic  acid  ointment. 

PEDICULOSIS  PUBIS. 

This  is  only  seen  after  puberty,  and  is  due  to  an  infection  of 
the  pubic  hair  by  the  pediculus  pubis,  or  crab-louse,  and  is,  of 
course,  not  seen  in  children  before  puberty. 

Occasionally  these  parasites  infect  the  eyebrows  and  eyelashes. 
The  parasites  are  smaller  than  the  other  forms  of  lice,  and  bury 
their  heads  in  the  hair  follicles.  The  nits  are  deposited  upon 
the  hair  and  hatch  in  about  the  same  time  as  the  other  varie- 
ties. 

The  lice  can  be  removed  with  forceps  and  the  nits  removed 
by  vigorous  rubbing  and  the  application  to  the  eyebrows  of  a 
carbolic  acid  ointment,  5  per  cent,  or  a  50  per  cent  mercurial 
ointment  with  vaseline. 

SCABIES  OR  ITCH. 

This  is  due  to  the  invasion  of  the  skin  by  the  sarcoptes 
scahiei  or  itch  mite,  and  is  characterized  by  burrows,  in  which 
the  female  lays  her  eggs,  and  intense  itching. 


DISEASES   OF   THE   SKIN.  579 

Symptoms. — It  is  a  comparatively  frequent  occurrence  in  chil- 
dren, and  especially  in  institutions,  newly  admitted  children 
often  bringing  the  infection.     It  is  highly  contagious. 

The  female  parasite  burrows  into  the  skin,  these  forming 
an  irregular  line  about  an  eighth  of  an  inch  in  length,  elevated, 
grayish  in  color. 

The  most  frequent  sites  of  the  burrows  are  the  back  of  the 
hands,  between  the  fingers;  the  wrists;  toes;  inner  sides  of  the 
thighs;  the  scrotum  in  males;  around  the  waist  and  axillary 
region. 

A  variety  of  eruptions  are  found  over  the  affected  areas, 
papules,  vesicles,  pustules,  and  excoriations  due  to  the  scratch- 
ing. 

Examined  under  a  magnifying  glass  the  acarus  can  be  seen 
at  one  end  of  the  burrow. 

The  chief  symptom  is  the  itching,  most  severe  at  night,  dis- 
turbing greatly  the  rest  and  sleep  of  the  child.  The  extent  of 
the  eruption  depends  upon  the  amount  of  pruritis  and  the  coin- 
cident scratching. 

Wearing  clothes  formerly  worn  by  an  infected  person,  using 
the  same  towels,  sleeping  with  one  infected,  or  in  an  unchanged 
bed  formerly  occupied  by  an  infected  person,  are  the  most  fre- 
quent means  of  propagation. 

The  female  acarus  is  considerably  larger  than  the  male,  easily 
seen  with  a  magnifying  glass.  It  is  yellowish  in  color  and  ovoid 
in  shape.  The  female  perishes  in  the  epidermis  after  depositing 
her  ova  in  the  burrow. 

Diagnosis  is  not  always  easy,  but  is  suspicious  whenever  a 
case  presents  with  severe  itching  and  the  multiform  eruption 
upon  the  body  as  described  above.  The  finding  of  the  burrows, 
not  always  easy,  is  the  diagnostic  sign.  Pediculi  affect  the  body 
almost  exclusively. 

Eczema  must  be  differentiated.  Except  as  a  complication  of 
scabies,  so  extensive  an  eczema  with  an  arrangement  as  in 
scabies  is  unlikely  to  occur. 

Treatment. — The  object  of  treatment  is  to  destroy  the  acarus 
and  relieve  the  resultant  skin  lesions.  Sulphur,  balsam  of  Peru 
and  tar  are  the  most  efficient  remedies. 


580  THE   DISEASES   OF    CHILDREN. 

The  child  is  given  a  hot  bath  with  thorough  soaping  and  vig- 
orous rub  with  rough  towel  afterward.  The  towel  is  boiled  be- 
fore again  being  used.  After  this  the  whole  body  affected  is 
anointed  w^th  an  ointment  containing  sulphur,  or  sulphur  and 
balsam  of  Peru,  as  follows: 

xl 


I^  Sulphur  precip. 

gf' 

Balsam  Peruv. 

3i 

Adipis 

Vaseline 

aa  3ss 

M.  ft.  ung. 

IJ  Beta  naphthol 

gr. 

Balsam  Peru 

3i 

or  Sulphur  precip. 

gr- 

Vaseline 

3i 

M.  ft.  ung. 

xl 


This  method  of  treatment  is  repeated  each  of  three  succeed- 
ing nights,  and  at  the  end  of  this  time  precipitated  sulphur  is 
sprinkled  between  the  sheets  at  bed  time.  Sheets  and  night 
clothes  are  changed  each  day. 

RINGWORM. 

Ringworm  is  named  according  to  the  site  affected,  of  the  scalp, 
tinea  tonsurans;  of  the  body,  tinea  circinata;  of  the  groin,  tinea 
cruris. 

Two  spore  fungi  have  been  found  as  cause,  of  these  conditions, 
the  small  spore,  microsporon  audouini,  and  the  large  spore, 
triclwphyton. 

There  are  several  varieties  of  each  fungus. 

TINEA  CIRCINATA. 

Lesions  due  to  the  microsporon  appear  on  any  part  of  the 
body,  often  upon  the  backs  of  the  hands. 

Symptoms. — It  begins  as  a  small,  scaly,  papular  patch,  soon 
assuming  a  circular  form,  the  outer  ring  generally  being  slightly 
elevated  and  scaly.  As  the  ring  enlarges  the  skin  within  be- 
comes shiny  and  tense  and  of  a  deeper  color  than  the  healthy 
skin.  One  or  two,  or  many  ringworm  patches,  may  be  found. 
It  may  occur  with  or  without  an  involvement  of  the  scalp. 


DISEASES   OP   THE   SKIN.  581 

One  source  of  infection  is  through  the  medium  of  domestic 
pets,  cats  and  dogs. 

Pathology. — A  scraping  from  the  scaly  patch,  treated  with 
liquor  potassae,  10  to  30  per  cent  solution,  after  10  or  15  min- 
utes shows  under  the  microscope  a  network  of  mycelial  threads, 
bifurcated,  with  fewer  spores.  The  latter  are  round,  about  1/800 
of  an  inch  in  diameter. 

.  Treatment. — Painting  the  patches  with  the  tincture  of  iodine 
is  usually  sufficient  to  cure.  This  may  be  repeated  once  daily 
for  two  or  three  days.  Any  of  the  parasiticide  drugs  in  the 
form  of  an  ointment  may  be  used  as  follows : 

li  Ung.    sulphuris  3! 

Ac.  carbolici  gr.  x 

M.  ft.  ung. 

I^  Hydrargyri  ammoniat.  gr.  xx 
ITiiff.    ziiici    oxidi 


Vaseline 
M.  ft.  ung. 

aa5ss 

IJ  Beta    naphthol 

Eesorcin 

Ung.   aqviae   rosae 
M.  ft.  ung. 

gr.xx 
gr.  xii 

31 

TINEA  TONSURANS. 

Synonyms. — Ringworm  of  scalp. 

A  disease  of  the  scalp  due  to  the  tricophyton  tonsurans,  char- 
acterized by  a  disease  of  the  hair  which  causes  it  to  fall  out, 
leaving  circumscribed  areas  of  baldness,  with  scaly  surface. 

Etiology. — This  disease  is  due  to  the  tricophyton  tonsurans, 
or  the  microsporon  audouini.  It  affects  children,  in  the  main, 
and  is  directly  transmitted  from  child  to  child,  or  through  the 
medium  of  combs  or  brushes,  towels,  caps,  bedding,  etc.  A 
cat,  dog  or  rabbit  may  convey  the  organism. 

Pathology. — An  examination  of  a  hair  from  the  diseased 
area,  or  a  scale  from  the  epidermis,  treated  with  a  20  per  cent 
potassa^  solution,  the  spores  can  be  easily  seen  under  the  scale 
when  viewed  witli  a  1/6  inch  lens.     They  are  attached  in  num- 


582  THE  DISEASES  OP   CHILDREN. 

bers  to  the  hair,  and  the  mycelial  threads  run  longitudinally. 
The  hair  is  broken  off  leaving  a  rough  end. 

Symptoms. — The  disease  begins  upon  any  portion  of  the 
scalp,  being  at  first  limited  to  the  scalp,  but  later  on  affecting 
the  hair  and  hair  follicle.  The  period  in  which  only  the  scalp 
is  involved  may  be  entirely  overlooked  as  practically  no  symp- 
toms present.  The  first  evidence  may  be  a  bald  spot  appearing 
upon  some  part  of  the  scalp,  the  hair  being  broken  off  and  the 
skin  in  the  area,  as  a  rule,  scaly  in  appearance.  These  areas 
vary  in  size  from  a  five-cent  piece  to  the  size  of  a  silver  dollar. 
On  an  attempt  to  pull  out  a  hair  in  the  diseased  area  the  hair 
breaks  close  to  the  scalp. 

A  differentiation  is  made  by  dermatologists  of  the  lesion  caused 
by  the  large  and  small  spores.  In  the  large-spored  type,  or  the 
tricophyton  or  endothrix  variety,  the  lesions  are  much  smaller 
in  size  than  the  sraall-spored  type. 

The  course  of  the  disease  is  slow  and  prolonged,  as  it  may 
remain  for  years  if  treatment  is  not  instituted  and  conscien- 
tiously carried  out. 

Diagnosis. — The  occurrence  of  circumscribed  areas  of  bald- 
ness in  one  or  more  places  in  the  scalp  is  characteristic  of  ring- 
worm. An  examination  of  the  hair  treated  by  liquor  potassae 
under  the  microscope  will  clear  up  the  diagnosis. 

It  must  be  diagnosed  from  alopecia.  This  is  usually  more 
rapid  in  its  course,  and  the  scalp  affected  smooth  and  soft,  the 
hair  apparently  normal,  at  least  not  brittle,  and  contains  no 
spores. 

Prognosis. — This  is  one  of  the  most  intractable  of  the  skin 
lesions  of  childhood,  and  requires  several  months  of  active  and 
persistent  treatment  before  a  cure  can  be  obtained. 

Treatment. — Careful  segregation  of  ringworm  subjects 
should  be  insisted  upon,  and  they  should  be  made  to  w^ear  a 
skull  cap  made  of  muslin  at  all  times  so  as  to  prevent  the  dis- 
semination of  scales  and  broken  hairs  containing  the  spores. 

The  hair  should  be  closely  clipped  from  the  whole  head,  or 
if  a  girl,  and  this  is  objected  to,  a  small  area  around  the  af- 
fected spot  should  be  closely  cut.  The  diseased  area  is  vigor- 
ously rubbed  with  green  soap,  or  its  tincture,  and  witli  a  nail 


DISEASES  OP  THE   SKIN,  583 

brush  thoroughly  scrubbed  each  morning,  followed  by  the  appli- 
cation of  the  medicament  decided  upon,  for  the  purpose  of  de- 
stroying the  spores.  This  can  be  done  only  by  producing  an 
inflammatory  reaction  in  the  skin  of  the  affected  area.  The  fol- 
lowing has  been  recommended  as  effective  for  this  purpose : 

I^   Sodium  chloridi 

Vaseline  aa  ^ss 

M.  ft.  ung. 

IJ  Sulphur  precipitat. 

Beta  naphthol  aa  3i 

Balsam  Peruv.  Sss 

Vaselini  ^i 

M. 


R  Hydrargyri  bichloridi 

gr.  i 

Kerosene  oil 

01.  olivse                     aa 

3S8 

Alcoholis                   q.s. 

5iv 

M. 

U  01.  Tiglii 

3i 

Sulphur  precipitat. 

3ii 

Vaseline 

3i 

M.  ft.  ung. 

Equal  parts  of  oil  of  cade  and  castor  oil  have  been  recom- 
mended. 

Anj^  one  of  these  applications  is  to  be  used  once  daily,  until 
an  inflammatory  reaction  is  obtained,  when  it  is  discontinued 
for  a  few  days,  and  a  simple  ointment,  as  a  3  per  cent  boracic 
acid  ointment  applied  until  the  reaction  disappears,  when  the 
original  ointment  is  again  applied. 

For  the  intractable  cases  the  X-rays  have  been  recommended, 
with  10  to  15  minutes'  exposure,  static  current  and  high  vacuum 
tube  are  suggested  as  most  beneficial. 

TINEA  FAVOSA. 

Synonym. — Favus. 

Etiology. — This  is  a  disease  most  frequently  affecting  the 
scalp,  due  to  a  mould  fungus,  Achorion  Schoenleinii,  and  is  con- 
tagious.    It  usually  begins  in  childhood,  and  most  frequently 


584  THE   DISEASES   OF    CHILDREN. 

among  the  poor,  especially  in  foreigners,  Poles,  Russians  and 
Jews.     The  domestic  pets  may  cause  its  dessemination. 

Pathology. — The  epidermis,  hair  and  hair  follicles  are  in- 
volved. The  crusts  which  form  in  favus  are  much  thicker  than 
in  ringworm,  it  is  cup-shaped,  the  scutulum,  yellowish  in  color, 
and  made  up  of  mycelia  and  spores.  The  area  beneath  a  scu- 
tulum is  red,  moist  and  free  of  hair.   ,  They  have  a  peculiar  odor. 

Symptoms. — The  scalp  is  more  often  affected,  and  also  areas 
of  the  body,  and  either  may  be  affected  alone.  The  occurrence 
of  the  favus  cup  or  scutulum,  the  size  of  a  split  pea,  the  con- 
cave side  up,  usually  with  a  hair  in  its  center,  is  the  first  diag- 
nostic sign,  and  when  dislodged  leaves  a  moist,  often  bleeding 
area,  slightly  depressed,  beneath.  If  the  inflammation  is  exten- 
sive, the  cups  may  coalesce.  The  hair  looks  dead,  but  is  not  as 
brittle  as  the  hair  in  ringworm.  Itching  is  usually  present. 
Healed  areas  on  the  scalp  show  slightly  depressed  bald  scars. 

Diagnosis  is  to  be  made  from  eczema  and  ringworm.  It  may 
be  difficult  to  make  a  diagnosis  from  ringworm  of  the  body  if 
the  characteristic  lesion  is  not  present  in  the  scalp  also.  The 
scutula  do  not  appear  in  any  of  the  other  diseases  mentioned. 

Prognosis. — This  is  very  unfavorable,  as  a  cure  is  obtained 
with  difficulty. 

Treatment. — The  hair  in  the  affected  area  must  be  pulled 
out  after  removing  the  scutula.  Applications  of  a  strong  solu- 
tion of  bicarbonate  of  soda  will  accomplish  this.  The  scalp  can 
be  soaked  with  oil  and  the  crusts  scraped  off.  Epilation  can 
proceed  when  the  affected  area  is  clean,  and  is  a  very  tedi- 
ous process,  as  each  hair  must  be  carefully  pulled  out  separately. 
Bulkley  recommends  the  following  stick  for  epilation : 


B 

Cerae  flavse 

3ii 

Laccse  in  tabulas 

3iv 

Picis  burgundicae 

3x 

Gummi  damar 

•    5isa 

M. 

Moulded  into  stick. 

The  end  of  the  stick  is  melted  and  when  warm  applied  to  the 
hair  and  twisted  off  when  cold. 

Any   of  the   applications   reconiineiidcd   for  tenia   tonsurans 


DISEASES   OF   THE   SKIN,  585 

can  be  used  to  advantage  in  favus,  followed  by  vigorous  cleans- 
ing with  green  soap  and  water. 

In  addition,  the  following  can  be  used : 

IJ  Chrysarobin  gr.  xv  to  xx 

Vaseline  ^i 

M. 

3  Hydrargyri    oleat.  gr.  x 

Vaseline  ^i 

M. 

IJ  Pyrogallol  5  per  cent. 

IJ  Acetic  acid  sprayed  on  the  scalp  in  an  atomizer. 

The  X-rays  may  be  used  in  intractable  cases  the  same  as  in 
ringworm  of  the  scalp. 

IMPETIGO  CONTAGIOSA. 

Etiology. — Due  to  the  invasion  of  the  skin  by  the  pus  organ- 
isms, and  it  is  common  among  the  children  of  the  poor.  It  is 
not  infrequently  epidemic  in  institutions,  when  it  once  obtains 
a  start.  Scratching  in  pruritus,  scabies  and  pediculosis  may 
cause  it. 

Pathology. — The  staphylococcus  aureus  is  believed  to  be  most 
regularly  present,  though  Fox  has  described  the  finding  of  the 
streptococcus  also. 

Symptoms. — The  initial  lesion  is  a  vesicle,  which  quickly 
changes  to  a  pustule,  varying  from  the  size  of  a  pin  head  to  a 
five-cent  piece.  The  pustules  rupture,  their  contents  forming 
in  a  scab  or  crust.  These  can  be  removed,  usually  being  at- 
tached to  the  hair,  and  leave  a  moist,  bleeding  area  beneath. 
The  pustules  and  the  encrustations  may  coalesce,  forming  one 
large  crust  over  the  affected  area.  They  are  very  superficial 
and  leave  no  scars. 

The  parts  affected  are  chiefly  the  exposed  parts  of  the  body, 
and  others  may  soon  become  affected  by  autoinoculation.  The 
glands  nearby  may  become  enlarged. 

Diagnosis. — The  very  superficial   character  of  the  vesicles, 


586  THE  DISEASES   OP    CHILDREN. 

pustules  and  crusts,  and  the  evident  inoculation  of  other  parts, 
is  enough  for  the  diagnosis.  It  is  to  be  diagnosed  from  pustu- 
lar eczema,  pemphigus  and  varicella,  and  should  be  easy. 

Treatment. — The  first  indication  is  to  remove  the  crusts.  No 
medication  will  be  of  avail  through  these.  Any  oily  substance 
will  soften  them,  and  they  can  be  washed  off  with  warm  water 
and  green  soap.  Bicarbonate  of  soda  solution  is  helpful  for  this 
also.     One  of  the  following  is  then  applied : 


IJ  Ichthyol  amnion. 

Vaseline 
M. 

sulph 

5iss 
5i 

IJ  Ung.  liydrargyri  anuuon.   clilor 

Vaseline 
M. 

5i 

IJ  Hydrargyri  chloridi  mitis 
Vaseline 

M. 

gr.  V 
5i 

B  Resorcin 

Ung.  aquae  rosae 

gr.x 
Si 

IJ  Acid  boracic 
Vaseline 

gr.xx 

3i 

M.  Sig. :  Useful  in  the  later  stages. 

Vaccines  may  be  found  beneficial  in  intractable  cases;  the 
mixed  stock,  staphylococcus  or  autogenous  vaccine  may  be  used. 

PEMPHIGUS  VULGARIS  ACUTA. 

This  is  a  rather  rare  condition  in  children.  Duhring  reports 
16  eases  in  16,863  cases  of  skin  disease.  It  is  characterized  by 
the  development  of  bullae  or  blebs,  with  more  or  less  constitu- 
tional symptoms. 

Other  varieties  of  pemphigus,  even  more  rare,  are  described, 
viz.,  pemphigus  vegetans  and  pemphigus  foUaceus. 

Etiology. — Nothing  is  known  definitely  of  the  causation  of 
this  disease.  There  may  be  a  connection  between  it  and  the 
nervous  system. 

Pathology. — The  blebs  may  involve  all  of  the  layers  of  the 


DISEASES   OP   THE   SKIN.  ^  587 

skin,  or  only  the  epidermis.  The  contents  of  the  blisters  is  a 
straw-colored  fluid,  containing  leucocytes,  and  an  infiltration  of 
the  entire  skin.  There  may  be  an  infection  of  the  bullae  and 
absorption  of  toxic  products. 

Symptoms. — Usually  there  are  systemic  symptoms  preceding 
the  development  of  the  blebs,  malaise,  rigors  or  a  chill,  with  a 
moderate  rise  of  temperature.  Slight  pain  or  a  stinging  sensa- 
tion may  be  felt  at  the  site  of  the  developing  bleb  or  bulla,  or  a 
macular  spot  may  develop,  followed  at  once  by  the  blister  upon 
it.  The  blisters  vary  from  the  size  of  a  split  pea  to  an  area 
2  or  3  inches  square.  They  have  no  areola.  The  bullse  develop 
in  successive  crops  for  six  or  seven  days,  as  a  rule.  The  skin 
of  all  parts  of  the  body  is  affected,  rarely  the  mucous  mem- 
branes. In  one  of  the  two  cases  reported,  the  blebs  formed 
upon  the  conjunctiva.  Cohen  has  described  one  case  of  this 
kind  occurring  in  50,000  eye  cases.  The  duration  of  an  attack 
is  three  or  four  weeks,  or  it  may  last  months. 

When  this  disease  develops  in  the  new-born,  or  shortly  after 
birth,  it  is  designated  pemphigus  neonatorum^. 

Diagnosis  is  from  varicella,  dermatitis  herpetiformis,  impetigo 
and  erythema  multiforme. 

The  latter  is  much  more  acute,  the  lesions  more  limited,  and 
there  is  an  erythematous  base. 

Prognosis. — These  cases  may  result  fatally,  especially  if  they 
run  a  chronic  course,  when  the  system  becomes  much  depleted. 
Hemorrhagic  extravasation  in  the  bullae  is  an  unfavorable  oc- 
currence. 

Treatment. — The  bullge  should  be  punctured,  under  aseptic 
precautions,  and  the  loose  skin  removed.  Mild  antiseptic 
applications  should  be  made  to  the  raw  surface  below;  5  per  cent 
boracic  acid  ointment  or  10  per  cent  ichthyol  ointment.  If  the 
process  is  very  extensive,  the  continuous  bath  treatment  for  sev- 
eral hours  at  a  time  is  efficacious. 

Internally,  arsenic  is  of  curative  value.  Fowler's  solution 
in  increasing  doses,  to  the  point  of  tolerance,  is  indicated.  Qid- 
nin  is  also  of  benefit,  in  2  to  5  grain  doses,  and  iron  in  the  stage 
of  coMvalescenee.  Nourishing  food  is  also  of  value,  and  the  diet 
should  be  closely  watched. 


588 


THE  DISEASES  OF   CHILDREN. 


The  following  cases  occurred  in  my  service  at  a  local  insti- 
tution, and  it  is  through  the  courtesy  of  Dr.  I.  N.  Bloom,  derma- 
Boy,  nine  years  old,  in  the  institution  four  months.     When  three  years 
old  had  a  number  of  boils  requiring  incision.     Vaccinated  four  weeks  be- 
lologist,  that  they  are  reported : 


Fig.  100. — Pemphigus  vulgaris  acuta. 

fore  with  mild  infection  of  site,  but  this  had  entirely  healed  10  days  pre- 
viously, and  the  scab  was  off.  Admitted  to  the  infirmary  with  a  tempera- 
ture of  101.6°  F.,  with  a  severe  chill  after  admission.  The  following  morn- 
ing there  was  a  hypcremic  blush  on  the  left  arm,  extending  from  the  point 
of  vaccination  to  the  tip  of  the  shoulder.  There  was  pain  at  this  point 
during  the  night.  At  the  upper  border  of  this  area  there  was  a  large  bulla 
2  by  4  inches,  which  contained  about  2  drachms  of  a  transparent  fluid. 
His  tongue  was  coated  a  dirty  white  and  breath  foul.  By  the  next  day  a 
general  bullous  eruption  had  developed,  72  bullae  being  counted.  All 
parts. of  the  body  were  affected,  but  the  chest  and  abdomen.  The  surface 
beneath  the  bulla;  was  red  and  moist,  having  the  appearance  of  a  scald. 
The  mucous  membrane  of  the  mouth  was  involved  in  the  same  process. 


DISEASES   OP   THE   SKIN. 


589 


The  left  arm  became  involved  almost  over  its  entire  extent,  the  palm  of 
the  hand  on  this  side  also  being  involved.  It  was  very  painful  before 
the  development  of  the  bullae  there. 

Epistaxis  occurred  on  the  fourth  and  fifth  days.  On  the  fifth  day  blebs 
developed  on  the  left  conjunctivae,  with  pain  and  photophobia.  The  scalp 
was  involved  on  the  seventh  dav  bv  a  number  of  bullae. 


Fig.    101. — Pemphigus. 

The  temperature  was  fluctuating,  rising  before  the  development  of  each 
new  crop  of  bullae. 

Kecovery  occurred  in  three  weeks. 

Girl,  eight  years  old,  rather  poorly  nourished,  in  Home  seven  weeks.  In- 
vasion marked  by  a  chill.  Temperature  chart  accompanies  report.  Eleva- 
tion of  temperature  with  each  new  crop  of  blebs.  The  largest  bleb  noticed 
was  the  result  of  coalescence  of  several,  3x3  inches,  and  held  about  3  ounces 
of  fluid.  Blebs  appeared  without  erythematous  base,  first  on  belly  wall, 
and  soon  after  on  legs.  The  belly  wall,  genitals,  legs,  thighs,  wrists  and 
dorsal  surfaces  of  hands  were  most  affected.  The  upper  arms  and  fore- 
arms were  comparatively  free.  Scattered  blebs  on  scalp,  face,  back,  but- 
tocks and  palms  of  hands  and  soles  of  feet.  One  bleb  developed  on  hard 
palate.  The  base  beneath  the  blebs  was  red  and  moist  and  did  not  bleed. 
Appetite  was  good,  bowels  regular.  Was  apathetic  except  when  lesions 
were  dressed. 


590  THE   DISEASES   OF   CHILDREN. 

The  disease  lasted  23  days,  with  a  slight  relapse  four  weeks  later. 

Fowler's  solution  was  given  internally,  tub  baths  for  temperature;  re- 
moval of  raised  epidermis  over  the  blisters,  and  raw  surfaces  covered  with 
gauze  spread  with  5  per  cent  boracic  acid  vaseline  ointment,  this  dressing 
confined  by  a  bandage. 

ECZEMA. 

This  is  one  of  the  most  important  of  the  skin  lesions  of  child- 
hood, not  only  because  of  its  prevalence  but  because  of  the  variety 
of  its  manifestations  and  clinical  types.  Fully  one-third  of  all 
skin  diseases  in  children  are  eczema. 

Etiology. — Much  discussion  has  been  indulged  in  as  to  the 
cause  of  this  disease,  with  the  subject  still  unsettled.  Bateman 
says  of  this  disease :  ' '  Eczema  is  a  non-contagious  eruption  gen- 
erally the  effect  of  an  irritant,  whether  externally  or  internally 
applied,  but  occasionally  produced  by  a  great  variety  of  irri- 
tants in  persons  whose  skin  is  constitutionally  very  irritable." 
The  constitutional  causes  are  most  important,  of  which  disorders 
of  the  digestive  system  are  most  frequent.  Chronic  constipa- 
tion, catarrhal  conditions  of  the  gastrointestinal  tract,  toxemia 
from  acute  indigestion  or  intestinal  putrefaction.  Rheumatic 
diathesis  and  anemia  are  also  given  as  causes.  Heredity  plays 
an  important  role.  The  part  the  nervous  system  plays  in  the 
etiology  is  not  well  known,  but  that  there  is  a  connection  is 
generally  recognized.  Dentition  may  be  associated  with  a  dis- 
tinct outbreak  of  eczema. 

Among  the  chemical  and  local  causes  are  mustard,  rhus,  iodo- 
form, certain  kinds  of  soap,  dyes,  exposure  to  cold,  irritating 
effect  of  rough  clothing,  improperly  washed  napkins,  etc. 

Pathology. — A  few  changes  are  common  to  practically  all 
clinical  types  of  eczema ;  a  dilatation  of  the  blood  vessels  of  the 
cerium;  an  edema  of  the  papillary  layer;  vesicles  under  the 
horny  layer.  Marked  cellular  infiltration  occurs  in  the  chronic 
form,  and  thickening  of  the  skin. 

Symptoms. — Clinically,  certain  changes  are  practically  com 
mou  to  the  several  varieties.  There  is  an  erythematous  ap- 
pearance of  the  skin,  with  formation  on  this  of  minute  vesicles. 
With  this  there  is  a  sense  of  burning  or  itching.  The  pruritus 
is  specially  prominent.  There  is  a  tendency  of  the  vesicles  to 
rupture  with  tlie  formation  of  a  moist  surface,  or  one  which 


DISEASES   OP   THE   SKIN",  591 

is  encrusted  or  scaly.  The  process  is  patchy  in  character  and 
there  is  a  tendency  to  frequent  exacerbations  and  recurrences 
or  relapses. 

Eczema  may  be  acute,  subacute  or  chronic,  and  occur  at  any 
age.  It  is  very  frequent  in  childhood.  Bulkley  states  that  in 
3000  cases  of  eczema  676  occurred  under  the  age  of  five  years, 
and  520  of  these  were  under  three  yars  of  age. 

It  has  a  special  predilection  for  the  face,  in  many  instances 
beginning  upon  the  face. 

The  following  varieties  of  eczema  may  be  recognized  clinic- 
ally: Eczema  erythematosum,  papulosum,  vesiculosum,  pus- 
tulosum,  squamosum. 

Eczemxi  Erythematosum.. — -Occurs  most  frequently  on  the  face, 
neck,  hands  and  buttocks.  As  the  name  implies  the  first  symp- 
toms are  erythematous  spots  which  quickly  coalesce.  When 
about  the  eyes  there  is  edema  of  both  lids.  The  skin  is  thick- 
ened, and  is  hot  and  dry.  Itching  and  burning  are  severe. 
]\loisture  may  be  present  if  there  is  much  scratching.  As  the 
inflammation  subsides  the  swelling  decreases  and  the  surface  is 
covered  by  small,  branny  scales.     This  form  may  become  chronic. 

Eczema  Papulosum. — This  affects  the  back,  arms,  hands  and 
legs  most  frequently.  There  is  an  eruption  of  dull  red  papules 
the  size  of  a  pin  head,  discrete  or  formed  in  small  groups.  These 
groups  may  coalesce  and  cover  larger  areas.  The  pruritus  in 
this  form  is  much  greater  than  the  others,  and  as  a  result  of 
the  scratching  the  tops  of  the  papules  are  scraped  off,  leaving 
bleeding  spots  which  become  inflamed  from  infection.  Kecur- 
rence  of  this  form  is  frequent. 

Eczema  Vesiculosum. — This  is  the  commonest  form.  The 
face,  neck,  hands  and  buttocks  are  oftenest  affected.  There  are 
fine  pin  head  size  vesicles  which  develop  on  an  erythematous 
base.  Itching  and  burning  precede  the  appearance  of  the  ves- 
icles. These  vesicles  coalesce  as  the  fluid  in  the  skin  forms,  rup- 
ture, and  the  coagulation  of  the  fluid  forms  a  crust  over  the 
surface.  New  vesicles  form  at  the  margins,  and  the  same  process 
is  repeated. 

The  duration  of  the  acute  symptoms  is  about  two  weeks.  If 
the  crust  is  removed  a  moist,  red  base  is  uncovered. 


592  THE  DISEASES  OF   CHILDREN. 

Eczema  Pustulosum. — If  an  infection  of  the  vesicular  form 
of  eczema  takes  place,  the  pustular  form  will  follow.  The  early 
signs  are  the  same  as  in  the  vesicular  type.  The  crusts  are 
much  thicker,  and  yellow  or  greenish  in  color.  It  is  most  often 
seen  on  the  face  and  head.  The  early  burning  and  itching  may 
be  present,  but  it  is  less  marked  after  the  pustules  form. 

Eczema  Squamosum,  may  be  a  primary  condition  or  any  of 
the  types  preceding  may  pass  through  the  squamous  or  scaly 
stage  before  complete  recovery.  The  skin  is  dry  and  covered 
with  a  fine  scale.  This  is  the  seborrheic  form,  and  occurs  most 
often  on  the  scalp  of  the  child,  often  behind  the  ears  and  the 
eyebrows.  When  on  the  scalp  it  is  the  * '  milk  crust ' '  of  the  laity. 
A  dirty  yellow  crust  covers  the  scalp,  and  if  it  has  been  untreated 
sometimes  is  quite  thick. 

Prognosis. — Because  of  its  proneness  to  recur,  the  prognosis 
as  to  a  cure  is  not  very  favorable.  The  earlier  treatment  is  be- 
gun the  more  chance  for  a  prompt  cure.  Chronic  cases  respond 
slowly. 

Treatment. — Attention  to  the  general  health  of  the  child  is 
indicated,  its  habits,  food,  bowels,  kidneys,  exercise,  clothing, 
bathing,  sleep,  etc.  Every  detail  of  its  life  should  be  minutely 
ascertained  as  often  a  trivial  cause  will  be  found  which  is  re- 
sponsible for  the  condition. 

Not  many  internal  remedies  have  been  found  of  service.  Ar- 
senic is  of  doubtful  value.  Wine  of  antimony  in  5  minim  doses 
has  been  recommended.  Turpentine  in  small  doses  has  been  rec- 
ommended by  Crocker. 

The  child  should  not  be  allowed  to  scratch  the  inflamed  area. 
This  can  be  prevented  by  pinning  the  hands  down  to  its  dress, 
a  rather  unnatural  method ;  by  tying  them  in  small  canton  flannel 
bags,  or  special  metal  hand  coverings,  and  by  having  the  child 
wear  a  mask  made  of  thin  muslin,  with  eyes,  mouth  and  nose 
uncovered.  Soap  and  water  should  be  kept  off  the  affected  areas 
entirely.  No  local  remedy  will  be  of  avail  if  an  attempt  is  made 
to  apply  it  through  the  crusts.  The  crusts  must  be  softened  by 
the  application  of  olive  oil  or  soda  solution  and  removed  by  a 
forceps. 

Among  the  indications  present  are  applications  of  soothing 


DISEASES  OF  THE  SKIN.  593 

remedies  in  the  acutely  inflamed  cases,  when  the  vesicles  form, 
applying  astringent  remedies.  Locally,  a  large  number  of  reme- 
dies have  been  suggested,  evidence  sufficient  to  decide  that  none 
is  effective  in  all  cases.  Lotions,  ointments  and  powders  are  the 
forms  in  which  remedies  are  applied  externally. 

In  the  acute  form  of  eczema  with  burning  and  itching,  any 
bland  ajiplication  is  of  benefit  as  lead  and  opium  wash ;  biborate 
of ^  soda  solution,  5i  to  Oi,  sopped  or  poured  on  several  times  a 
day.  In  the  vesicular  form,  dusting  powders  are  helpful;  tal- 
cum, starch,  magnesium  carbonate,  stearate  of  zinc,  etc.  Las- 
sar's  paste  is  of  benefit  as  a  bland  and  unirritating  application. 

The  following  applications  are  recommended: 


I^  Tinct.  picis  liquidse 

3i 

Acidi   phenici 

gr.  xl 

Glycerine 

Siss 

Zinci  oxidi 

3ii 

Ext.    hamamelis    dest. 

3i- 

q.s.  ad 

Bvi 

M. 

( Schamberg. ) 

IJ  Zinci  oxidi 

Amyli 

3ii 

Vaseline  - 

388 

M.  ft.  paste. 

IJ   Zinci  oxidi 

388 

Pulv.  calamine  prep. 

3iv. 

Glycerine 

5i 

Aq.   ealcis 

5viii 

M. 

(Startin.) 

In  the  chronic  form  several  drugs  are  of  value,  viz.,  tar,  resor- 
cin,  salicylic  acid,  gelatin,  chrysarobin,  sulphur,  ichthyol,  silver 
nitrate,  diachylon  ointment,  oil  of  cade,  etc.,  and  can  be  combined 
in  many  formulae. 

HERPES. 

Synonyms. — Fever  blister.     Cold  sore. 

Defimtion. — A  collection  of  vesicles  upon  the  skin  upon  a 
common  reddened  base.     They  may  occur  upon  the  face,  herpes 


594  THE   DISEASES  OP    CHILDREN. 

facialis;  upon  the  lips,  herpes  labialis;  upon  the  genitals,  her- 
pes genitalis;  upon  the  body,  herpes  zoster. 

Symptoms. — This  eruption  may  occur  independently  or  in 
connection  with  various  febrile  disorders,  as  pneumonia,  tonsil- 
litis, acute  "colds,"  cerebrospinal  meningitis,  etc. 

The  first  symptom  is  a  sense  of  burning  and  swelling,  fol- 
lowed by  a  reddened  base,  and  shortly  by  the  crop  of  small 
vesicles,  pin  head  in  size  or  larger.  The  vesicles  may  rupture 
and  form  crusts.  Successive  crops  may  develop  for  several  days, 
and  there  is  a  tendency  for  them  to  recur. 

Diagnosis. — From  eczema  and  impetigo.  The  latter,  with 
great  rarity,  occur  in  single  patches. 

Treatment. — No  special  treatment  is  required.  The  diges- 
tion must  be  watched,  the  diet  regulated  and  the  bowels  put  in 
good  condition.  In  recurrent  cases,  arsenic  is  of  value.  Locally, 
when  the  first  symptom  is  noticed,  the  application  of  camphor 
or  tincture  of  myrrh  is  of  service;  as  soon  as  the  vesicles  have 
ruptured,  dry  calomel  applied  will  be  of  service,  or  an  ointment 
of  calomel  and  vaseline,  gr.  x  to  §i,  or  5  per  cent  boracic  acid 
ointment. 

HERPES  ZOSTER. 

Synonym. — Shingles. 

Definition. — An  acute  inflammatory  condition  of  the  skin 
characterized  by  the  formation  of  vesicles,  distributed  along  the 
course  of  the  cutaneous  nerves,  and  accompanied  by  neuralgic 
pains.     A  comparatively  rare  condition  in  young  children. 

Etiology. — Season  plays  a  part  in  etiology,  it  occurring  more 
frequently  in  winter  and  spring.  Exposure  to  cold  is  also  a 
cause.  There  seems  to  be  an  intimate  relationship  between  the 
lesion  in  the  skin  and  the  change  in  the  nerve  trunk,  possibly  an 
interstitial  neuritis  of  the  peripheral  nerves,  or  of  the  sensory 
ganglia  of  the  posterior  nerve  roots. 

Symptoms. — After  a  brief  period  in  which  sharp,  burning 
neuralgic  pains  are  felt  over  the  region  affected,  successive 
crops  of  vesicles  appear,  following  the  course  of  the  nerve 
involved.  Papules  and  macules  precede  the  vesicular  stage  a 
very  short  time.     As  a  rule  but  one  side  is  affected  at  a  time. 


DISEASES   OF   THE   SKIN.  595 

The  most  frequent  parts  affected  are  the  areas  supplied  by  the 
intercostal  and  trifacial  nerves.  Some  fever  may  attend  the  for- 
mation of  the  vesicles. 

Diagnosis. — Any  vesicular  eruption  occurring  upon  one  side 
of  the  body  and  following  fairly  accurately  the  course  of  a  per- 
ipheral nerve  is  difficult  to  mistake  for  any  other  disease. 

Treatment. — Protection  of  the  eruption  from  injury  or  in- 
fection is  the  first  indication.  It  may  be  painted  with  tincture 
of  benzoin,  or  an  ichthyol  collodion  dressing,  oi  to  '^i,  or  an 
ichthyol  ointment  can  be  used. 

Internally  sedatives  may  be  necessary  for  the  pain,  heroin  or 
codeine. 

Quinin  and  arsenic  are  useful  through  the  course  of  the 
disease. 

The  application  of  the  galvanic  current  is  most  beneficial, 

PRURITUS. 

In  this  condition  there  is  no  special  pathology  except  that 
produced  by  the  irritation  due  to  scratching.  Itching,  however, 
is  a  prominent  symptom  of  a  number  of  the  skin  diseases  of 
children;  urticaria,  scabies,  eczema,  sudaimna,  pediculosis,  etc. 
It  also  occurs  at  the  anus,  pruritus  ani,  as  a  result  of  intestinal 
worms. 

An  itching  of  the  skin  is  evidenced  by  restlessness  in  the 
very  young,  disturbed  sleep,  and  rubbing  with  hands  and  feet. 
The  itching  is  usually  intensified  when  the  child  is  undressed, 
caused  by  the  air  striking  the  skin.  As  a  result  of  the  scratch- 
ing the  skin  may  become  infected  and  an  impetigo  result.  Much 
infiltration  of  the  skin  results  from  long-continued  scratching. 

An  underlying  general  or  systemic  condition  may  be  the  cause 
of  the  condition  acting  through  the  nervous  system,  especially 
the  cutaneous  nerves. 

Treatment. — If  possible,  the  diagnosis  must  be  made  giving 
appropriate  treatment  to  the  cause  found.  Internally,  tonics 
and  nerve  sedatives  are  of  value;  locally,  the  antipruritic  rem- 
edies afford  temporary  relief.  Bathing  in  a  strong  solution  of 
bicarbonate  of  soda,  or  a  solution  of  starch,  allowed  to  dry  on 
the  skin,  and  ointments  containing  any  of  the  following,  or  a 


596  THE  DISEASES  OF   CHILDREN. 

combination  of  them,  will  prove  effective;  camphor,  menthol, 
chloral,  acid  carbolic,  liquor  potassae,  thymol,  etc. 

URTICARIA. 

Synonyms. — Nettle  rash,  hives,  lichen  urticatus. 

A  number  of  varieties  may  occur,  urticaria  factitia,  urticaria 
papulosa  (lichen  urticatus),  urticaria  tuberosa,  urticaria  hemor- 
rhagica, urticaria  bullosa. 

Etiology. — This  is  generally  considered  as  a  cutaneous  man- 
ifestation of  a  gastrointestinal  disorder  with  a  resulting  toxemia, 
and  eithei*  food  or  drugs  may  cause  the  same  conditions.  One 
family  under  my  observation  is  peculiarly  susceptible  to  quinin, 
it  producing  a  general  urticaria  in  four  members;  one  cannot 
eat  ripe  fruit,  berries  or  peaches  without  a  severe  case  of  urti- 
caria, etc.  The  antitoxic  sera,  before  their  purification  and  elim- 
ination of  the  globulins  from  them,  frequently  caused  both  a 
local  and  general  urticarial  rash. 

Pathology. — The  process  is  most  likely  an  angioneurosis. 
The  process,  as  outlined,  may  be  papular,  vesicular  or  bullous  in 
character. 

Symptoms. — The  eruption  appears  suddenly  and  without 
warning,  the  most  common  variety  appearing  as  raised  papules 
or  wheals  of  vajious  sizes,  with  whitish  tops  and  a  red  base. 
These  are  accompanied  by  a  sense  of  burning  and  severe  itching. 
They  may  be  localized  or  the  whole  body  may  be  affected.  In 
the  urticaria  factitia,  letters  can  be  traced  on  the  skin,  and  they 
will  stand  out  in  bold  relief  in  a  few  minutes.  The  name  der- 
mographism has  been  given  to  this  phenomenon. 

The  form  in  which  large  wheals  appear  is  usually  of  short 
duration,  the  fine  papular  form  may  last  a  number  of  weeks. 

Prognosis. — The  chronic  form  of  urticaria  is  very  unprom- 
ising, and  fortunately  is  comparatively  rare  in  children.  The 
acute  form  is  quickly  recovered  from,  but  has  a  tendency  to 
recur. 

Treatment. — In  the  acute  cases,  a  brisk  purgative  is  of  bene- 
fit, and  careful  regulation  of  the  diet  will  assist  in  the  cure  and 
prevent  a  recurrence.  Inquiry  as  to  special  articles  of  diet 
should  be  made,  in  an  effort  to  trace  the  direct  cause  of  dis- 


DISEASES   OF   THE   SKIN.  597 

agreement.     Milk  of  magnesia  is  a  good  remedy  to  correct  the 
acidity  as  well  as  for  its  laxative  effect. 

Locally,  the  application  of  a  hot  bicarbonate  of  soda  solution 
or  a  general  bath  containing  the  soda,  is  of  benefit.  The  fol- 
lowing lotion  is  recommended  by  Schamberg: 


Menthol. 

gr.  XXX 

Acidi    phenici 

f3i 

Tinct.  picis  mineralis 

3i-ii 

Ext.  hamamelis  dest. 

Si 

Zinci  oxidi 

3ii 

Glycerini 

3ii 

Spt.  vini  rect. 

Sii 

Aquae   camphorse 

3ii 

Aquse  dest.          q.s.  ad 

Jviii 

PSORIASIS. 

M. 


This  is  not  an  uncommon  condition  in  childhood.  It  is  evi- 
denced by  irregular  patches  with  sharp  cut  edges,  the  center 
covered  with  whitish  scales.  They  are  found  most  often  on  the 
extensor  surfaces  of  the  extremities,  later  perhaps,  on  the  fore- 
head, scalp,  and  trunk. 

This  condition  has  a  tendency  to  disappear  during  the  summer 
months,  recurring  in  winter.  It  is  rather  intractable  to  treat- 
ment. Removal  of  the  scales,  application  of  a  2  per  cent  oint- 
ment of  ehrysarobin  will  prove  of  benefit. 


APPENDIX. 
MILK  MODIFICATIONS. 

]\Iathematical  equations  are  the  basis  of  the  majority  of  meth- 
ods for  the  modification  of  milk,  and  one  of  these  should  be 
selected  by  the  physician,  memorized  and  used. 

The  following  are  some  of  the  most  practical  which  have  been 
suggested, 

BANER'S  METHOD. 

The  method  devised  by  Baner  is  probably  the  most  useful 
and  practical;  it  is  as  follows:  Determine  the  quantity  to  be 
fed  in  24  hours  and  the  percentage  of  the  ingredients,  and  use 
the  following  formula : 

Q  =  quantity  in  24  hours ;  C  =  cream  in  ounces.  ( In  the 
following  equation  if  a  20  per  cent  cream  is  used,  16  will  be 
the  divisor ;  if  a  16  per  cent  cream  is  used,  12  will  be  the  divisor ; 
and  if  a  12  per  cent  cream  is  used,  8  will  be  the  divisor.) 
M  =  whole  milk  in  ounces;  F  =  percentage  of  fat  in  the  mix- 
ture; P  =  the  proteids,  and  L  (lactose)  ^dry  sugar  of  milk  in 
ounces : 

OX  (F  —  P) 

C  = (if  12  per  cent  cream  is  used.) 

8 

QXP 

M  = C 

4  (i.e.,  the  proteids  in  cow's  milk.) 

W  =  Q—  (C  +  3/). 

{L—P)XQ 

L.  = (result  being  in  ounces). 

100 

Let  20  ounces  be  the  quantity  to  be  fed  in  24  hours  (10  feed- 

598 


APPENDIX.  599 

ings  of  2  ounces  each)  and  the  formula  be:  Fat,  2  per  cent; 
sugar,  6  per  cent;  proteids,  1  per  cent;  the  equation  will  be  as 
follows : 


20  X  (2  —  1)        20 
0  = =  —  =  2i  oz. 


20X1 

M^=> 2i  =  5  —  2J  =  2i  oz. 

4 

TF  =  20—  (2*4-  2i)  «20  — 5  =  15  oz. 

(6  — 1)  X20       5X20       100 

M.  S.  =  ———  = =. =1   oz. 

100  100  100 

Ordinary  gravity  cream  contains  16  per  cent  of  butter  fat, 
and  if  2  parts  of  this  are  added  to  1  part  of  milk  (containing  4 
per  cent  fat),  12  per  cent  cream  will  be  obtained. 

Westcott  has  also  devised  mathematical  formulae  for  calcu- 
lating milk  mixtures  as  follows: 

C  =  cream  in  ounces ;  M  =  whole  milk  in  ounces ;  F  ^  fat ; 
P  =  proteids ;  L  =  lactose,  sugar  of  milk,  dry  in  ounces ;  Q  = 
total  quantity ;  S  =  sugar  percentage : 

(F  —  P)Q 

0=  ■■ 

8.2    (12  p.  c.  cream)   or  12.4   (16  p.  c.  cream)   or  16.8   (20  p.  c.  cream) 

QF 

M^ 3C  (12  p.  c.)   or  4C  (16   p.  c.)  or  5C   (20  p.  c.) 

4 

QS  — 4.3  (il/  +  C). 

L= ■ 

100 

If  a  20  ounce  mixture  is  desired,  containing  3  per  cent  of 
fat,  6  per  cent  of  sugar,  and  2  per  cent  of  proteids,  using  16 
per  cent  cream,  the  formula  would  read : 


(3  —  2)  20         20 

C  = = =1.6  oz. 

12.4  12.4 


600  THE   DISEASES   OP    CHILDREN. 

20X3 
M  = (4  X  1-6)  =15  — 6.4  =  8.6   oz. 


20x6  —  4.3(8.6-1-16)        120  —  43.9 

L  = =  =  0.76  oz.  t=.  f  oz. 

100  .  100 

Conversely,  in  order  to  determine  the  percentage  of  ingredi- 
ents in  any  combination  of  cream,  milk  and  sugar,  Westcott 
suggests  the. following: 

To  find  the  percentage  of  fat : 

C 

—  X  16  (or  12)  =  fat  percentage  from  cream. 
Q 

M 

—  X  4r=ifat  percentage  from  milk. 

Q 

Sum  of  these  =  fat  percentage  in  mixture. 
To  find  the  percentage  of  proteids : 

O 

—  X  3.6  (16  p.  c.)  or  3.8  (12  p.  c.)  =  proteid  percentage  from  cream. 
Q 

M 

—  X  ■*  "=  proteid  percentage  from  milk. 

Q 

Sum  of  these  ^  proteid  percentage  in  mixture. 

lOOL-l-4.3  (M-^C) 
Sugar  percentage  = 


Q 

An  illustration:  Take  the  above  mixture,  1.6  ounces  of  16  per 
cent  cream,  8.6  ounces  of  milk,  %  ounce  of  lactose,  and  191/2 
ounces  of  water: 

1.6 

X  16       ^=  1-28  per  cent  fat  from  cream. 

20 

8.6 

X    4       z=  1.72   per  cent   fat   from   milk. 

20 

1.28  -|-   1.72  =  3.0  total  per  cent  fat  in  mixture. 

1.6 

X    3.6    =  0.28  proteid  per  cent  from  cream. 

20 


8.6 

X    4 

20 


APPENDIX, 


1.72  proteid  per  cent  from  milk. 


0.28+    1.72  =  2.00  total  proteids  in  mixture. 
100  X    0.76  +  4.3  X  102       76  +  43.9 


20 


20 


6  per  cent  sugar. 


601 


Wescott  has  also  devised  a  scale  on  cardboard  discs  which 
show  the  amount  of  each  ingredient  to  use. 


Fig.    102. — Westcott's    milk    modification    chart. 

Hamilton's  method  is  based  on  the  fact  that  cream,  milk 
and  skimmed  milk  contain  relatively  the  same  amount  of  pro- 
teids and  salts : 

Multiply  quantity  of  the  mixture  by  the  percentage  of  fat 
desired  and  divide  by  the  percentage  of  cream  used,  the  quo- 
tient equals  the  amount  of  cream. 

Multiply  the  quantity  of  milk  mixture  by  the  percentage  of 
proteids  desired,  and  divide  by  4,  the  percentage  of  proteids  in 
skimmed  milk ;  subtract  from  this  the  amount  of  cream  to  be 
used,  the  result  equals  the  amount  of  skimmed  milk. 

The  quantity  of  cream  and  skimmed  milk  subtracted  from 


602 


THE  DISEASES   OP    CHILDREN. 


the  total  quantity  gives  the  amount  of  diluent.  Three  drachms 
of  lactose  must  be  added  to  each  10  ounces  of  the  mixture. 

Example. — Forty  ounces  of  mixture  desired,  of  the  following 
formula:  Fat,  4;  sugar,  7;  proteids,  2;  16  per  cent  cream. 

40  X  4  -:-  16  =  10  ounces  of  16  per  cent  cream. 

40  X  2  ^    4  —  20  —  10  =  10  ounces  of  skimmed  milk. 

40  —  20  =  20  ounces  of  diluent. 

Sugar  ^4  level  tablespoonfuls. 

Lime  water,  q.  s. 

Connor's  table. 
The  following  is  Connor's  table  for  milk  modification: 


>5  W  « 
O  hg 

p,  "^  w 


PER  CENT  FAT. 


as. 


0.13 
0.14 
0.17 
0.20 
0.25 
0.33 
0.40 
0.50 
0.62 
0.67 
0.75 


a 

:i 

fl 

a 

<D 

a 

'a 

O 

«^-s 

<B 

o^_. 

a 

<o^~. 

0 

C3 

C3 

aa 

Sb 

oB 

^^ 

ftB 

^Z^ 

«!-( 

!0  a 

r-4  qj 

N  a 

^  qj 

5D  a 

^ 

^r'o 

*r.2 

■tS'o 

rH   qj 

■^"o 

.  *" 

asi 

OS'S 

ajS 

+^"0 

*>'J3 

"S"® 

£* 

TL^ 

«  a 

00    (I) 

02    02 

M    S 

•  OS 

T  0) 

•      gj 

Is 

O  ^ 

°  a 

1-1  ■'^ 

1-(i-»M 

i.a 

ga 

CCHM 

CS 

r^  P4 

.(N 

-N 

.CO 

.M 

§"* 

&^ 

O 

O 

p.^ 

&-^ 

O 

S 

Eh 

1.00 

f^ 

in 

Eh 

0.50 

0.75 

1.25 

1.50 

1.75 

2.00 

0.57 

0.80 

1.14 

1.43 

1.71 

2.00 

2.30 

0.67 

1.00 

1.33 

1.67 

2.00 

2.34 

2.67 

0.80 

1.20 

1.60 

2.00 

2.40 

2.80 

3.20 

.1.00 

1.50 

2.00 

2.50 

3.00 

3.50 

4.00 

1.33 

2.00 

2.67 

3.33 

4.00 

4.66 

5.33 

1.60 

2.40 

3.20 

4.00 

4.80 

5.60 

6.40 

2.00 

3.00 

4.00 

5.00 

6.00 

7.00 

8.00 

2.50 

3.75 

5.00 

6.25 

7.50 

8.75 

10.00 

2.67 

4.00 

5.33 

6.67 

8.00 

9.33 

10.67 

3.00 

4.50 

6.00 

7.50 

9.00 

10.50 

12.00 

«  O 

W  PS 
fe  ft, 


giM 


0.41 
0  46 
0.54 
0.65 
0.81 
1.08 
1.30 
1.63 
2.03 
2.16 
2.44 


ft, 


1" 
o 


0.50 
0.57 
0.67 
0.80 
1.00 
1.33 
1.60 
2.00 
2..50 
2.67 
3.00 


MILK  MODIFIERS. 

Several  modifiers  of  milk  have  been  introduced,  the   Haas' 


APPENDIX. 


603 


]\Iaterna.  the  Deming  Modifier  and  Sloane  Maternity  Milk  Set. 
The  Materna  is  a  16  ounce  glass  graduate  with  pouring  tip. 
The  outer  surface  is  divided  into  seven  panels.  One  of  these 
shows  the  ounce  graduation,  the  other  six  show  as  many 
formulcB,  so  arranged  as  to  be  suitable  for  the  entire  first  year's 
feeding.  Having  determined  on  the  formula  desired,  the 
respective  ingredients  are  poured  into  the  graduate  to  the  line 
designated  for  the  substance  then  inserted.  First,  the  milk 
sugar  is  put  in,  then  warm  water  or  whatever  diluent  is  deter- 


»!'5!^rr;z.s:A£i;: 


,1  —  PATINTB 

\\  ClREO  CO.- 


Fig.    103. — Haas'    Matorua. 


Fig.     104. — Deming    Modifier. 


mined  upon,  in  which  this  is  dissolved,  the  lime  water,  the 
cream  and  then  the  milk;  the  ingredients  are  then  thoroughly 
stirred,  and  resultant  mixture  should  anal^^ze  the  same  as  the 
formula  at  the  top  of  the  panel  used,  16  per  cent  or  gravity 
cream  and  whole  milk  are  used  in  the  mixture.  Enough  bottles 
for  the  24  hours  are  filled  to  the  required  amount,  stopped  with 
absorbent  cotton,  kept  on  ice,  and  each  bottle  warmed  to  blooct 
heat  when  used.  The  following  are  the  markings  on  the  panels 
of  the  Materna: 


604 


THE  DISEASES   OP   CHILDREN. 


1 

2 

3 

4 

5 

6 

Fat.  2% 

Proteids,  0.6% 

Sugar,  6% 

MILK 

Fat,  2i% 

Proteids,  1% 

Sugar,  6% 

MILK 

Fat,  3% 

Proteids,  1% 

Sugar,  6% 

MILK 

Fat,  3}% 

Proteids,  li% 

Sugar,  7% 

MILK 

Fat,  4% 

Proteids,  2% 

Sugar,  7% 

MILK 

Fat.  3i% 

Proteids,  2i% 

Sugar,  3i% 

MILK 

Cream 

Cream 

Cream 

Cream 

Cream 

Lime-water 

Lime-water 

Lime-water 

Water 

Lime-water 

Water 

Water 

Milk-sugar 

Milk-sugar 

Water 

Lime-water 

• 

Water 

Milk-sugar 

Milk-sugar 

Barley  gruel 

Milk-sugar 

Gr.  sugar 

X 

X 

— X 

X 

X 

The  Deming  percentage  milk  modifier  is  a  16  ounce  grad- 
uate, its  graduations  and  percentages  being  based  on  whole 
and  top  milks  containing  3.2  per  cent  proteids  and  4  per  cent, 
7  per  cent,  10  per  cent  and  12  per  cent  fat : 

Directions. — Look  in  the  column  headed  proteids  for  desired 
percentage  of  proteids.  Then  move  to  the  right  until  the 
desired  percentage  of  fat  is  found  in  line  with  the  percentage 


APPENDIX. 
GRADUATIONS   AND    MARKINGS. 


605 


OUNCES. 

PEOTEIDS. 

Top  line. 

I-AT 

16 

Use 

Use 

Use 

Use 

7  p.c.  milk  or 

10  p.c.  milk  or 

12  p.c.  milk  or 

4  p.c.  milk  or 

the  top  16  oz. 

the  top  11  oz. 

the  top  9  oz. 

14 

whole  milk. 

from  one 

from  one 

from  one 

quart. 

quart. 

quart. 

per  cent. 

per  cent. 

per  cent. 

per  cent. 

per  cent. 

12 

2.4 

3.0 

5.2 

7.5 

9.0 

2.2 

2.7 

4.8 

6.8 

8.2 

10 

2.0 

2.5 

4.4 

6.2 

7.5 

1.8 

2.2 

3.9 

5.6 

6.7 

8 

1.6 

2.0 

3.5 

5.0 

6.0 

1.4 

1.7 

3.0 

4.3 

5.2 

6 

1.2 

1.5 

2.6 

3.7 

4.5 

1.0 

1.2 

2.2 

3.1 

3.7 

4 

.80 

1.0 

1.7 

2.5 

3.0 

.60 

.75 

1.3 

1.8 

2.2 

2 

.40 

.50 

.88 

1.3 

1.5 

1 

.20 

.25 

.44 

.62 

.75 

of  proteids.  Now  look  at  the  head  of  this  fat  column  to  find 
what  strength  of  milk  to  use.  Pour  this  milk  into  the  modifier 
up  to  the  desired  percentage  of  proteids  and  add  gruel  or  water 
to  "top  line."     This  will  make  16  ounces. 

The  percentage  of  sugar  in  the  mixture  will  be  almost  exactly 
the  same  as  the  percentage  of  proteids : 

1  level  tablespoonful     of  granulated   sugar  adds  2i/^%. 

2  level  tablespoonfuls  of  granulated  sugar  add  5  %. 
iy2  level  tablespoonfuls  of  milk  sugar  add     2i/^%. 

3  level  tablespoonfuls  of  milk  sugar  add  5  %. 
Slide  a  knife  over  the  bowl  of  the  spoon  to  make  it  level  full. 
Example. — To  make  a  mixture   3  per  cent  fat,  6  per  cent 

sugar  and  1  per  cent  proteids,  look  in  the  proteid  column  for 
1  per  cent.  At  the  right  of  this  will  be  found  3.1  per  cent  in 
the  third  column  of  fat  percentages,  which  is  headed:  "Use 
10  per  cent  milk  or  the  top  11  ozs.  from  1  qt. "  Obtain  1  quart 
of  good,  fresh  milk,  and  when  the  cream  shows  plainly  dip  oif 
the  top  11  ounces  into  a  pitcher  or  bowl,  and  stir  to  mix.  The 
first  dipperful  will  have  to  be  removed  with  a  teaspoon  or  the 
bottle  will  overflow  when  the  dipper  is  inserted.  Pour  this 
milk  into  the  modifier  up  to  the  1  per  cent  proteids  line.  Then 
fill  with  gruel  or  water  to  "top  line."     Add  5  per  cent  sugar — 


606  THE   DISEASES   OP    CHILDREN. 

2  level  tablespoonfuls  of  granulated  sugar  or  3  of  milk  sugar — 
and  stir  to  dissolve  the  sugar.  To  add  5  per  cent  or  10  per  cent 
of  lime  water  to  the  mixture,  leave  out  1  ounce  of  gruel  or  water 
for  5  per  cent  or  2  ounces  for  10  per  cent,  and  replace  with 
lime  water. 

After  the  cream  has  risen  on  a  quart  of  4  per  cent  milk,  there 
may  be  dipped  from  the  top  7  ounces,  16  per  cent  fat ;  8  ounces, 
14  per  cent ;  9  ounces,  12  per  cent ;  10  ounces,  11  per  cent ;  11 
ounces,  10  per  cent;  13  ounces,  9  per  cent;  15  ounces,  8  per 
cent;  16  ounces,  7  per  cent;  20  ounces,  6  per  cent;  24  ounces, 
5  per  cent;  for  4  per  cent  milk  or  whole  milk  shake  the  bottle 
to  mix  the  cream  and  milk;  to  obtain  fat-free  milk  dip  off  the 
cream  and  use  the  remaining  milk. 

As  the  modifier  is  marked,  50  combinations  of  fat  under  4 
per  cent  may  be  had  with  proteids  below  2  per  cent,*  and  36 
with  proteids  below  1  per  cent.  But  by  using  the  above-men- 
tioned milks  12  different  percentages  of  fat  may  be  had  with 
each  percentage  of  proteids.  When  half  graduations  are  used 
proteids  may  be  varied  by  .10  per  cent,  and  fat  by  .12  per  cent, 
.15  per  cent,  .19  per  cent,  .22  per  cent,  .25  per  cent,  .31  per 
cent,  .35  per  cent,  .38  per  cent,  .44  per  cent  or  .50  per  cent,  at 
a  time,  giving  over  200  hundred  combinations  of  fats  and 
proteids. 

The  Sloane  Modifier,  Cragin's  method,  consists  of  a  glass 
holding  20  ounces,  and  Chapin's  Cream  Dipper,  holding  1 
fluid  ounce.  The  following  directions  are  given  for  the  use 
of  this  modifier: 

From  the  upper  part  of  a  quart  bottle  which  has  stood  four 
hours  are  obtained  two  kinds  of  top  milk ; 

Top  ]\Iilk  No.  1. — Obtained  by  taking  10  dipperfuls  from 
the  top  of  the  bottle,  the  first  dipper  being  filled  with  a  spoon 
to  prevent  spilling,  the  remaining  9  dipperfuls  being  taken 
by  dipping,  carefully  from  the  bottle.  These  10  dipperfuls  are 
to  be  mixed  in  a  clean  pitcher,  and  from  the  milk  thus  mixed 
the  baby's  food  may  be  prepared  until  it  is  from  four  to  six 
months  old. 

Top  ]Milk  Xo.  2. — Obtained  by  taking  16  dipperfuls  from  the 
top  of  the  bottle,  the  first  dipper  being  filled  as  before  with  a 


APPENDIX. 


607 


spoon,  the  remaining  15  dipperfuls  being  taken  by  dipping 
carefully  from  the  bottle. 

These  16  dipperfuls  are  to  be  mixed  in  a  clean  pitcher,  and 
from  the  milk  thus  mixed  the  baby's  food  may  be  prepared 
from  the  age  of  about  four  months  until  it  is  a  year  old. 

In  using  this  milk  set.  whatever  strength  of  food  is  desired, 
the  sugar  and  the  lime  water  are  always  the  same:  1  ounce  of 
milk  sugar  (or  i/^  ounce  of  granulated  sugar)  and  1  ounce  (1 
dipperful)   of  lime  water. 

The  quantity  of  food  made  by  filling  the  glass  once  is  always 
the  same — 20  ounces.  The  strength  of  the  food  varies  with 
the  number  of  dipperfuls  of  top  milk  used. 

Preparation  of  the  Food. — First,  into  the  measuring  glass 
pour  milk  sugar  up  to  the  line  marked  1  ounce  milk  sugar,  or 
granulated  sugar  up  to  the  line  marked  one-half  ounce  granu- 
lated sugar. 

Second. — Add  1  dipperful  of  lime  water  and  mix  by  shaking 
the  glass. 

Third. — Add  the  required  number  of  dipperfuls  of  top  milk, 
according  to  the  age  of  the  baby,  as  explained  below. 

Fourth. — Fill  the  measuring  glass  up  to  the  line  marked  20 
ounces  of  food  with  water,  either  plain  or  barley  water  or  oat- 
meal water. 


Age  of  infant. 


1  week     .  . 

2  weeks   .  . 
4  weeks   .  . 

6  weeks   .  . 
8  weeks   .  . 

3  months 

4  months 

5  months 
G  months 

7  montlis. 

8  montlis 
n  months 

10  montlis 

1 1  months 

12  months 


Interval 

in 

hours. 


2 
2 
2 

2J 

2i 

2i 

2i 

3 

3 

3 

3 

3 

3 

3 

3 


No.  of  feed-  No.  of 

ings  in  night 

24  hours.  feedings. 


10 

10 

9 

8 


Amount 

ounces  at 

each  feeding. 


1 

U 

2i 

3 

3i 

4 

4i 

54 

5| 

6i 

7 

7 

8J 

8f 

9 


Total 

amount 

ounces  in 

24  hours. 


10 

15 

22* 

24 

26 

28 

3H 

33 

34J 

374 

42 

42 

424 

43| 

45 


608  THE  DISEASES  OF   CHILDREN. 

Formula  on  which  the  Average  Healthy  Baby  may  be  started: 

Premature   No.  1  or  2 

2-4  weeks   No.  5,  8,  9,  or  11 

1-2  months   No.  12  or  13 

2-4  months      No.  19  or  20 

4-6  months   No.  24  or  25 

6-8  months  No.  26  or  27 

8-9  months   No.  28 


TABLE   FOB    ESTIMATION    OF    FAT    PERCENTAGES    IN    CBEAMS. 

One  quart  of  whole  milk,  of  4  per  cent  fat,  will  yield  on  an  average 
approximately : 

Cream 10  per  cent  in  the  upper     8  oz.  after  6  hours. 

Cream 10  p«r  cent  in  the  upper  11  oz.  after  8  to  12  hours. 

Cream 12  per  cent  in  the  upper     8  oz.  after  8  hours. 

Cream 16  per  cent  in  the  upper     6  oz.  after  8  hours. 

Cream 20  per  cent  in  the  upper     4  oz.  after  4   to   6   hours. 


WHEY  CREAM  MIXTURES. 

Whey  cream  mixtures  may  be  obtained  by  using  whey  as  a  diluent,  in 
place  of  the  boiling  water,  preferably  in  the  combinations  containing  low 
proteid  percentages.  Each  2  ounces  of  whey  replacing  an  equal  quantity 
of  water  in  a  twenty-ounce  mixture,  will  raise  the  whey  proteid  percentage 
0.10,  and  will  increase  the  sugar  percentage  0.50.  The  total  sugar  percent- 
age is,  therefore,  the  amount  contributed  by  the  cream  and  fat-free  milk, 
which  is  indicated  in  the  last  column  of  the  table  on  the  reverse  of  the 
card,  plus  that  of  the  whey.  The  amovmt  of  dry  sugar  which  must  be 
added  to  make  the  desired  final  sugar  percentage  can  be  easily  calculated 
by  reference  to  the  following  table: 

1  measure  of  dry  lactose  in  a  20-oz.  mixture  gives  2.00  per  cent  of  sugar. 

i  measure  of  dry  lactose  in  a  20-oz.  mixture  gives  1.00  per  cent  of  sugar. 

I  measure  of  dry  lactose  in  a  20-oz.  mixture  gives  0.50  per  cent  of  sugar. 

(One  measure  is  approximately  one  level  tablespoonful. ) 

ExAMPLK — If  in  formula  21  fourteen  ounces  of  whey  are  added  in  place  of 
the  same  quantity  of  water,  the  whey  proteids  are  increased  0.70  per  cent, 
making  total  proteids  of  1.30  per  cent.  The  sugar  contributed  by  the 
cream  is  0.78,  by  the  whey  3.50,  making  a  total  of  4.28.  The  desired  per- 
centage of  sugar  is  6,  therefore  the  balance  of  1.72  per  cent  may  be  obtained 
by  adding  a  little  short  of  one  measure  of  sugar. 

Whey  should  be  made  of  fat-free  milk,  and  should  be  heated  to  150°  F. 
(65°  C.)  before  it  is  added  to  the  cream  mixture,  to  destroy  the  rennet 
enzyme.     One    quart    of    fat-free    milk  will  yield  about  24  ounces  of  whey. 


APPENDIX. 


609 


During  the  first  month  it  is  usually  better  to  use  plain  water, 
after  that  barley  water,  or  if  the  baby  is  very  constipated,  oat- 
meal water. 


MODIFICATION    OF    MILK LADD'S    TABLE 


TWENTY-OUNCE  MIX- 

OUNCES OF 

OUNCES  OF  FAT- 
FREE  MILK  USED 

OUNCES 

00 

^ 

TURES 

,  PERCENTAGE  OF 

CEEAM 

WITH  CREAMS  OF 

OF 

o 
u 

■^ 

u 

a> 

S 

u 

NO. 

Fat. 

Sugar 

.1 

« 

o 

« 

w 

t> 

o 

o 

« 

V 

OS 

-a 

CS 

3 

o 

"oa 

a. 

e. 

a. 

si. 

si 

a. 

a. 

». 

a 

OJ 

M 

s» 

u 

M 

o 

at 

^ 

o 

o 

e< 

« 

o 

13 

'3 

1 

Ul 

P^ 

< 

»H 

*-t 

1-1 

0) 

»H 

**i 

>-( 

0> 

« 

^ 

1 

1.50 

4.50 

0.25 

5 

* 

* 

* 

ii 

*' 

* 

* 

0 

17i 

2 

0.33 

2 

1.50 

4.50 

0.50 

5 

3 

2i 

2 

0 

J 

1 

li 

16 

2 

0.61 

3 

2.00 

5.00 

0.25 

5 

«c 

* 

2 

* 

* 

* 

0 

17 

2i 

0.75 

4 

2.00 

5.00 

0.50 

5 

* 

3i 

2i 

2 

^ 

0 

i 

1 

15i 

2i 

0.73 

5 

2.00 

5.00 

0.75 

5 

4 

3| 
3J 

2| 
2| 

2 

j 

H 

2i 

2J 

14i 

2 

1.01 

6 

2.00 

5.50 

1.00 

5 

4 

2 

u 

2i 

3i 

3 

13i 

2i 

1.30 

7 

2.50 

6.00 

0.50 

5 

* 

* 

3i 

3| 

2} 

* 

0 

■ 

151 

2i 

0.73 

8 

2.55 

6.00 

0.75 

5 

* 

4:- 

2 

* 

i 

IJ 

2 

14* 

2i 

1.01 

9 

2.50 

6.00 

1.00 

5 

5 

4: 

3J 

2| 

1 

n 

2i 

3i 

13* 

24 

1.23 

10 

3.00 

6.00 

0.50 

5 

* 

* 

3i 

3 

* 

* 

0 

■ ' 

15i 

24 

0.84 

H 

3.00 

6.00 

0.75 

5 

* 

* 

31 

3 

* 

0 

U 

2 

14 

24 

1.12 

12 

3.00 

6.00 

1.00 

5 

6 

5 

3 

3 

0 

1 

2i 

3 

13 

2i 

1.35 

13 

3.00 

6.00 

1.25 

5 

6 

5 

3 

3 

li 

2i 

3* 

4J 

11} 

2i 

1.35 

14 

3.00 

6.50 

1.50 

5 

6 

5 

3| 

3 

3i 

4| 

5} 

lOJ 

2i 

1.91 

15 

3.00 

6.50 

2.00 

5 

6 

5 

3J 

3 

5i 

6i 

7} 

8i 

74 

2 

2.68 

16 

3.50 

6.00 

0.50 

5 

* 

* 

* 

3* 

* 

* 

* 

0 

15* 

24 

0.78 

17 

3.50 

6.00 

0.75 

5 

* 

* 

4i 

3} 

* 

* 

0 

1 

144 

24 

1.01 

18 

3.50 

6.50 

1.00 

5 

* 

5J 

4i 

3i 

* 

0 

li 

2i 

13J 

24 

1.26 

19 

3.50 

6.50 

1.25 

5 

7 

5i 

4i 

3i 

Jl 

IJ 

3 

4 

114 

24 

1.68 

20 

3.50 

6.50 

1.50 

5 

7 

5J 

4i 

3i 

2' 

3J 

4i 

5J 

10 

2i 

2.02 

21 

4.00 

6.00 

0.60 

5 

* 

* 

* 

4 

* 

* 

* 

0 

15 

2* 

0.78 

22 

4.00 

6.00 

0.75 

5 

* 

* 

5 

4 

* 

* 

0 

1 

14 

24 

1.12 

23 

4.00 

7.00 

1.00 

5 

* 

* 

5 

4 

* 

* 

1 

2 

13 

2} 

1.35 

24 

4.00 

7.00 

1.25 

5 

* 

6f 

5 

4 

* 

5 

2J 

3i 

114 

24 

1.68 

25 

4.00 

7.00 

1.50 

5 

8 

6i 

5 

4 

1 

2i 

4i 

5 

10 

24 

2.02 

26 

4.00 

7.00 

2.00 

5 

8 

6} 

5 

4 

3^ 

4} 

6i 

7i 

74 

2i 

2.56 

27 

4.00 

7.00 

2.50 

5 

8 

6i 

5 

4 

6| 

7i 

9J 

lOi 

43 

2 

3.20 

28 

4.00 

7.00 

3.00 

5 

8 

6J 

5 

4 

9i 

lOJ 

12i 

13f 

1} 

14 

3.88 

29 

4.00 

6.00 

3.00 

5 

8 

6J 

5 

4 

^i 

10* 

12J 

13i 

1} 

1 

3.88 

30 

4.00 

5.50 

3.00 

5 

8 

6i 

5 

4 

9J 

loA 

12i 

13J 

IJ 

} 

3.88 

Combination  impossible  with  percentages  of  cream  indicated. 

For  2.')0unce  mixtures  multiply  the  amount  of  each  ingredient  by  1\. 
For  30-ounce  mixtures  multiply  the  amount  of  each  ingredient  by  14. 
For  35-ounce  mixtures  multiply  the  amount  of  each  ingredient  by  l|. 
For  40-ounce  mixtures  multiply  the  amount  of  each  ingredient  by  2. 
For  45-ounce  mixtures  multiply  the  amount  of  each  ingredient  by  2i. 


Strength  of  the  Food  for  Different  Months.— i^iVsf  Day. 
Give  no  milk ;  put  in  milk  sugar  to  mark,  then  fill  with  boiled 
water. 

Second  Day. — Add  1  dipperful  of  top  milk  No.  1. 


610  THE   DISEASES   OF    CHILDREN. 

Third  Day. — Add  2  dipperfuls  of  top  milk  No;  1. 

Fourth  Day. — Add  3  dipperfuls  of  top  milk  No.   1. 

Fifth  to  Tenth  Day. — Add  4  dipperfuls  of  top  milk  No,  1. 

Tenth  to  Thirtieth  Day. — Add  5  dipperfuls  of  top  milk  No.  1. 

One  Month  to  Two  Months. — Add  6  dipperfuls  of  top  milk 
No.  1. 

Two  Months  to  Four  Months. — Add  7  dipperfuls  of  top  milk 
No.  1. 

Four  Months  to  Nine  Months. — Add  10  dipperfuls  of  top 
milk  No.  2. 

When  the  baby  needs  more  than  20  ounces  in  the  24  hours, 
fill  the  measuring  glass  twice  instead  of  once,  before  putting 
the  food  into  the  baby's  bottle. 

After  nine  months  the  food  is  prepared  by  shaking  the  quart 
bottle  of  milk  when  first  obtained  and  using  the  plain  mixed 
milk. 

HALE'S  METHOD. 

Hale  ^  suggests  the  following  method  of  modifications : 
Rule  1. — To  find  the  percentage  of  fat  (or  sugar  or  proteid) 
in  anj'^  mixture  multiply  the  number  of  ounces  used  of  each 
fat  (or  sugar  or  proteid)  containing  factor  by  the  percentage 
of  fat  (or  sugar  or  proteid)  it  contains,  and  divide  the  sum  of 
fat  (or  sugar  or  proteid)  results  by  the  number  of  ounces  in  the 
whole  mixture. 
Example. — A  mixture  is  made  up  of 

2  ounces  of  10  per  cent  cream, 
10  ounces  of  whole  milk, 
§  ounce  of  lactose, 
8  ounces  of  water, 

20  ounces  in  all,  and  we  apply  the  rule. 
Fat  from  cream,  2  ounces  multiplied  by  10  per  cent  equals.  .20  parts  of  fat 
Fat  from  milk,  10  ounces  multiplied  by  4  per  cent  equals.  .40  parts  of  fat 

60  parts.  The 
sum  of  fat  re- 
sults. 


'  Archives  of  Pediatrics,  May,  1908. 


APPEjmiX.  611 

Sugar  from  cream,  2  ounces  multiplied  by  4.50  per  cent 

equals     9  parts  of  sugar 

Sugar  from  milk,  10  ounces  multiplied  by  4.50  per  cent 

equals 45  parts  of  sugar 

Sugar   from   lactose,   0.66   ounce  multiplied  by   100  per 

cent    equals    66  parts  of  sugar 

120  parts.  The 
sum  of  sugar  re- 
sults. 

Proteids  from  cream,  20  ounces  multiplied  by  3.50  per 

cent    equals     7  parts  of  proteids 

Prot«ids  from  milk,   10  ounces  multiplied  by  3.50  per 

cent   equals    35  parts  of  proteids 

42  parts.     The   sum 
of  proteid  results. 

These  sums  divided  by  20,  the  number  of  ounces  in  the  mix- 
ture, will  give  the  percentages  desired,  thus: 

20)    60  per  cent  fat,         120  per  cent  sugar,  42  per  cent  proteids. 

3  per  cent  fat,  6  per  cent  sugar,         2.1  per  cent  proteids. 

These  percentages  represent  the  amount  of  fat,  sugar  and 
proteids  the  mixture  contains,  and  with  this  knowledge  we  can 
intelligently  appreciate  the  strength  and  proportion  of  the  in- 
gredients, and  are  prepared  to  reduce  to  grams,  and  then  esti- 
mate the  caloric  values.^ 

This  example  is  given  to  make  Rule  1  more  clear.  The  fol- 
lowing data  is  obtained  from  the  mother : 

In  each  bottle  she  puts 

2  ounces  of  milk. 

1  ounce  of  cream. 

i  ounce  of  lime  water. 
2J  ounces  of  water. 
1  heaping  teaspoonful  of  lactose,  equal  to  J  ounce. 2 

6  ounces. 

'  An  ounce  equals  29.5  grams.  One  gram  of  fat  yields  9.3  calories.  Proteids 
and  sugar  each  yield  4.1   calories  per  gram. 

'■'  A  Chapin  ounce  dipper,  even  full  of  milk-sugar,  varies  in  weight  from  245 
grains  to  280  grains  Troy,   with  simple  moderate  juggling  to  settle  it.     When  sugar 


612  THE   DISEASES   OF    CHILDREN. 

What  she  has  told  us  so  far  means  very  little,  and  we  must 
inquire  further.  This  we  do,  discovering  that  the  milk  is 
skimmed  milk,  and  that  the  cream  is  from  the  top  6  ounces  of 
the  bottle.  Thus  the  milk  used  would  run  about  .75  per  cent 
fat,  4.150  per  cent  sugar,  3.50  per  cent  proteids,  and  the  cream 
about  18  per  cent  fat,  4.50  per  cent  sugar,  and  3.25  per  cent 
proteids.  Having  learned  these  facts  we  proceed  to  apply 
Kule  1,  first  for  fat,  next  for  sugar,  and  last  for  the  proteids. 

The  totals  then  are  divided  by 

Milk      — 2        oz.  multiplied  by      0.75  p. c.  equals    1.50  parts  of  fat  from  the  milk. 
Cream  — 1        oz.  multiplied  by    18.00  p.c.  equals  18.00  parts  of  fat  from  the  cream. 


which  gives  us  19.50  parts  of  fat  in  all. 

Milk      — 2        oz.  multiplied  by      4.50  p.c.  equals    9.00  parts  of  sugar  from  the  milk. 
Cream  — 1        oz.  multiplied  by      4.50  p.c.  equals    4.50  parts  of  sugar  from  the  cream. 
Lactose — 0.20  oz.  multiplied  by  100.00  p.c.  equals  20.00  parts  of  sugar  from  the  lactose. 


which  gives  us  33.50  parts  of  sugar  in  all. 

Milk      — 2        oz.  multiplied  by       3.50  p.c.  equals    7.00  parts  of  proteids  from  the  milk. 
Cream  — 1        oz.  multiplied  by       3.25  p.c.  equals    3.25  parts  of  proteids  from  the  cream. 


which  gives  us  10.25  parts  of  proteids  in  all. 
The  totals  then  are  divided  by 

6)      Fat,    19.50  parts.  Sugar,    33.50  parts.  Proteids,   10.25  parts. 

3.25  p.c.  fat.  5.58  p.c.  sugar.  1.70  p.c.  proteids.' 

Rule  2. — To  find  the  number  of  ounces  of  any  factor  (be  it 
cream,  milk,  etc.,  or  sugar)  that  must  be  used  to  obtain  any 
desired  percentage  of  fat  (or  sugar  or  proteids),  multiply  the 
number  of  ounces  in  the  whole  mixture  by  the  percentage  of  fat 
(or  sugar  or  proteids)  desired,  and  divide  the  result  by  the  per- 
centage in  which  the  fat  (or  sugar  or  proteids)  occurs. 

Example. — ^We  wish  to  make  up  a  30  ounce  mixture,  contain- 
ing 2.50  per  cent  fat,  using  whole  milk  and  water.  Thirty 
ounces  multiplied  by  2.50  per  cent  equals  75;  this  divided  by 
4  per  cent  gives  18.75  ounces  as  the  number  needed  to  give  the 
required  amount  of  fat. 

By  way  of  further  example,  we  will  make  up  a  thirty  ounce 
mixture,  containing  2.50  per  cent  of  fat,  6  per  cent  of  sugar,  and 


is  loosened  in  its  can.  or  carton,  and  dipped  out,  a  heaping  tablespoonful  varies  from 
235  grains  to  338  grains.  The  damper  and  more  sticky  the  sugar  the  more  will 
remain  on  the  spoon,  Mallinckrodt's  and  Merck's  running  heavier  than  Squibb's. 
A  dipped  and  then  struck  tablespoonful  runs  from  140  grains  to  172  grains.  Here 
more  of  the  sticky  sugar  pushes  off  than  of  the  dry.  A  dipped  heaping  teaspoonful 
runs  from  85  to  100  grains,  averaging  approximately  1  to  5  ounces.  A  dipped  and 
then  struck  teaspoonful  holds  from  39  to  47  grains. 


APPENDIX.  613 

1.75  per  cent  of  proteids.  Here  the  problem  is  complicated 
by  the  fact  that  the  fat  and  proteids  must  both  be  entirely 
derived  from  the  milk.  The  first  step  is,  therefore,  to  ascertain 
the  relation  which  the  fat  and  proteids  bear  to  each  other.  To 
do  this  we  divide  the  percentage  of  the  proteids  by  the  per- 
centage of  the  fat;  thus,  1.75  divided  by  2.50  gives  .7.  "Which 
means  that  the  relation  of  proteids  to  fat  is  as  .7  is  to  10. 

We  now  endeavor  to  find  what  portion  of  a  bottle  of  milk 
has  fat  and  proteids  in  this  proportion,  or  approximately  so. 
In  looking  back  over  the  percentages  of  fat  and  proteids  in 
different  portions  of  a  bottle,  our  eyes  light  upon  the  upper 
25  ounces,  which  contain  5  per  cent  fat  and  3.50  per  cent 
proteids,  exactly  the  thing  we  want.  Having  now  found  a 
milk  with  the  fat  and  proteids  in  the  proportions  desired,  we 
proceed  at  once  to  find  the  number  of  ounces  necessary  to  give 
the  required  percentage  of  either  the  fat  or  proteids.  It  makes 
no  difference  which  is  chosen  to  work  with,  the  proportion  re- 
mains undisturbed.  We  will  choose  to  work  it  out  for  the 
proteids.  Applying  Rule  2,  we  multiply  30  ounces  by  1.75, 
which  gives  52.50;  this  divided  by  3.50  per  cent  gives  15 
ounces  as  the  number  of  ounces  needed  to  supply  both  fat  and 
proteids  in  the  desired  amounts.  We  notice  that  in  this  case 
the  amount  of  milk  happens  to  be  half  of  the  bulk  prepared, 
consequently  the  dilution  is  one-half,  which  proves  our  calcula- 
tion and  tells  us  further  that  the  sugar  supplied  by  the  milk  is 
one-half  of  4.50  per  cent;  that  is,  2.25  per  cent,  making  it  un- 
necessary for  us  to  work  it  out  by  Rule  1.  There  is,  then,  2.25 
per  cent  of  sugar  supplied ;  3.75  per  cent  must  still  be  added 
to  make  up  the  required  6  per  cent.  We  apply  Rule  2  and 
multiply  30  ounces  by  3.75  per  cent,  which  gives  112.50,  and 
this  divided  by  100  per  cent  (the  percentage  of  sugar  in  lac- 
tose) gives  1.125  ounces  as  the  amount  of  lactose  that  must  be 
used.  This  amounts  to  simply  finding  what  3.75  per  cent  of 
30  ounces  is,  as  we  realize  that  3.75  per  cent  should  be  written 
.0375. 

The  upper  third  contains  three  times  as  much  fat  as  proteids ; 
that  is,  in  the  ordinary  bottled  milk  it  contains  about  10  per 
cent  fat  and  a  shade  less  than  3.50  per  cent  -proteids.     The 


614  THE   DISEASES   OF    CHILDREN. 

upper  half  contains  twice  as  much  fat  as  proteids;  that  is,  7 
per  cent  fat  and  3.50  per  cent  proteids. 

In  the  use  of  10  per  cent  milk  it  is  very  simple,  for  to  obtain 
a  certain  percentage  of  fat  in  the  20  ounce  mixture  it  is  only 
necessary  to  multiply  the  desired  percentage  by  2  to  find  the 
amount  of  milk  needed.  This  is  clear  when  we  look  at  it  a 
little  more  closely.  One  ounce  in  20  is  evidently  in  the  same 
proportion  as  5  in  100;  that  is,  5  per  cent.  This  1  ounce  is 
only  1/10  fat,  so  the  amount  of  fat  it  gives  is  1/10  of  5  per 
cent,  which  is  .50  per  cent,  or  I/2  per  cent;  that  is,  one-half  the 
number  of  ounces  used.  For  every  1  per  cent  of  fat  desired 
2  ounces  of  such  a  milk  must  be  used  in  each  20  ounce  mixture. 

The  proteids  are  one-third  fat;  thus,  1  ounce  of  this  10  per 
cent  milk  yields  scant  .17  per  cent  proteids  in  a  20  ounce  mix- 
ture. 

The  sugar  is  a  little  less  than  half  the  fat,  or  about  .23  per 
cent  in  the  20  ounce  mixture.  As  lactose  is  100  per  cent  sugar, 
each  ounce  added  increases  the  sugar  just  5  per  cent. 

In  using  the  upper  half  of  the  ordinary  bottled  milk,  the 
calculations  may  be  done  as  follows:  This  milk  contains  7 
per  cent  fat,  4.50  per  cent  sugar,  and  3.50  per  cent  proteids; 
that  is,  the  proteids  are  just  half  the  fat,  and  the  sugar  is 
.64,  or  approximately  two-thirds  of  the  fat,  and  may  be  so  con- 
sidered. We  have  seen  that  1  in  20  is  5  per  cent.  One  ounce 
of  milk,  7  per  cent  fat,  in  a  20  ounce  mixture  gives  to  the 
mixture  that  part  of  5  per  cent  which  7  per  cent  is  of  100  per 
cent,  namely,  1/14.3 ;  1/14.3  of  5  per  cent  is  .35  per  cent ; 
therefore,  each  ounce  gives  .35  per  cent  of  fat,  which  is  con- 
sidered l^  per  cent.  This  enables  us  at  a  glance  to  tell  how 
man3^  ounces  are  needed  to  give  any  desired  percentage,  namely, 
three  times  as  many  ounces  as  per  cent  of  fat  wished. 

The  proteids  in  the  mixture  would  be  in  the  same  proportion 
as  in  the  milk  used,  namely,  half  the  fat. 

The  sugar  would  also  be  in  the  same  proportion  as  in  the 
milk ;  that  is,  two-thirds  as  much  as  the  fat. 

Example. — We  wish  3  per  cent  fat,  and  take  9  ounces  from 
the  upper  half  of  a  bottle.  Applying  Rule  1  as  a  test,  the  mix- 
ture is  seen  to  contain  3.15  per  cent  fat,  which  is  close  enough. 


APPENDIX.  615 

"We  will  now,  by  way  of  a  more  complete  example,  take  a 
formula  and  work  it  out.  We  wish  in  every  24  hours  to  give 
a  baby  33  ounces  of  a  mixture  containing  2.50  per  cent  fat, 
7  per  cent  sugar,  and  1.25  per  cent  proteids.  In  order  to  have 
a  margin  for  waste  and  possible  breaking  of  a  nursing  bottle, 
we  will  make  up  40  ounces.  This  will  require  just  twice  what 
the  20  ounces  do.  To  make  up  a  20  ounce  mixture  with  2.50 
per  cent  fat,  we  take  as  many  ounces  of  the  7  per  cent  milk  as 
three  times  the  percentage  of  fat  desired.  This  gives  7.50 
ounces  as  the  number  to  be  used.  For  40  ounces  twice  as  much 
is  taken. 

The  sugar  is  two-thirds  of  the  fat ;  that  is,  1.66  per  cent  of 
sugar  is  supplied  by  the  milk.  We  desire  7  per  cent,  so  there 
is  lacking  5.44  per  cent;  that  is,  5  per  cent,  and  approximately 
1/10  of  5  per  cent  more.  One  ounce  of  lactose  gives  the  5 
per  cent,  and  1  drachm  more  is  near  enough  to  the  1/10  desired. 
Thus,  1  ounce  and  1  drachm  will  bring  the  sugar  up  to  7  per 
cent  in  the  20  ounce  mixture,  twice  as  much  will  be  needed  in 
the  whole  amount  being  mixed. 

The  proteids,  because  of  their  proportion,  must  be  one-half 
the  fat;  that  is,  1.25  per  cent  (or  exactly  1.30  per  cent),  the 
percentage  wished.  The  whole  mixture  will  then  be  made  as 
follows : 

15  ounces  upper  half  of  bottle. 

25  ounces  water. 

2J  ounces  lactose. 

40  ounces 

MOFFITT'S  METHOD  OF  CALCULATION. 

Moffitt  ^  recommends  the  following  method  of  calculation  of 
various  formula?;  taking  average  herd  milk  to  show  the  fol- 
lowing analysis:  fat  4  per  cent,  carbohydrates,  4.5  per  cent, 
proteins,  3.5  per  cent,  and  16  per  cent  cream  to  show  fat,  16 
per  cent,  carbohydrates  4.05  per  cent,  proteins,  3.2  per  cent. 

Suppose  a  represent  the  per  cent  of  fat,  h  the  per  cent  of 
carbohydrates,  and  c  the  per  cent  of  proteins  in  any  artificial 
mixture;  that  is,  that  which  is  commonly  known  as,   for  ex- 

^  Jovmal  American  Medical  Association,  vol.  Iv,   no.   22. 


616  THE   DISEASES   OF    CHILDREN, 

ample,  a  3-6-1  mixture  (3  per  cent  of  fat,  6  per  cent  of  car- 
bohydrates, and  1  per  cent  of  proteins)  we  term  an  a-h-c  mix- 
ture. Now  let  X  represent  the  per  cent  of  milk,  y  the  per  cent 
of  cream,  and  z  the  per  cent  of  milk-sugar  necessary  to  com- 
pound such  a  mixture.  The  diluent  will  then  be  equal  to 
100-(x+y). 

It  is  then  obvious  that 

4x       16y 

— -  -j- =  a  or  X  -|-  4y  =  25a     ( 1 ) 

100       100 

4.5x      4.05y 

and  + 4-z  =  b  or   90x -f  Sly -f  2,000z  =  2,000b (2) 

100        100 

3.5x      3.2y 

also -f, =  c  or  35x  +  32y  =  1,000c. 

100       100 

By    subtracting   Equation    1    multiplied   by    8    ( 8x -j- 32y  i=i  200a )    from 
Equation  3  we  have 

1,000c  — 200a 

27x  =  1,000c  —  200a  or  x  = 

27 
By  subtracting  Equation  3  from   Equation   1,  multiplied  by  35    (35x4- 
140y  =  875a),  We  have 

875a— 1,000c 

108y  .=>  875a  —  1,000c  or  y  = 

108 

By  substituting  these  values  of  x  and  y  in  Equation  2  we  have 
90  (1,000c  — 200a)       81  (875a  — 1,000c) 

-f 1-  2,000z  c=i  2,000b 

27  108 

that    is    40,000c  — 8,000a  +  7.875a  — 4,000c -f24,000zc=.  24,000b 

a  4-  192b  —  248c 

or  z  = 

192 

We  then  have  the  values  of  x.  y  and  z  in  terms  of  a,  b  and  c;  that  is  to 
say,  we  have  the  per  cent  of  milk,  cream  and  milk-sugar  necessary  to  make 
up  an  a-b-c  mixture,  and  any  values  whatever  (of  fat,  carbohydrate  and  pro- 
tein percentages),  such  as  3,  6  and  1  may  be  substituted  for  a,  b  and  c. 
Our  formula  then  is 

1,000c  — 200a 

per     cent    of     milk         = ( 1 ) 

27 
875a  —  1,000c 

per    cent    of    cream       i=i ( 2 ) 

108 
a+  192b  — 248c 

per  cent   of   milk-sugar  = (3) 

192 
To   demoiistrate   the   accuracy   of   the   calculation   in    devising   this   for- 


APPENDIX.  617 

mula,  suppose  we  desire  a  4-4.5-3.5  mixture,  i.e.,  a  mixture  containing  4 
per  cent  of  proteins.     It  will  be  seen  that  this  is  cow's  milk. 
Substituting  3.5  for  c  and  4  for,  a  in   (1),  we  have 

1,000  X  3.5  —  200  X  4       3,500.0  —  800       2,700 

■ — = ^ =  100 

27  27  ■      27 

Substituting  likewise  in   (2),  we  have 

875  X  4  —  1,000  X  3.5       3,500  —  .3,500.0 


0 


108  108 

Substituting  these  values  in   (3),  and  also  4.5  for  b,  we  have 
4-1-192X4  5  —  248x3.5        4 -|- 864.0  —  868.0 


0 


192  192 

showing  that,  m  compounding  a  4-4.5-3.5  mixture,  we  take  100  parts  milk, 
no  cream,  no  sugar  and  no  diluent. 

Now  suppose  we  desire  a   16-4.05-3.2  mixture    (cream). 

Substituting  3.2  for  c  and   16   for  a  in    (1),  we  have 

1,000  X  3.2  —  200  X  16       3,200.0  —  3,200 
= =  0 


27  27 

Substituting  likewise  in    (2),  we  have 

875  X  16  —  1,000  X  3.2       14,000  —  3,200.0       10,800 

108  108  108 

Substituting  these  values  in   (3),  and  also  4.05  for  b,  we  have 
16  -I-  192  X  4.05  —  248  X  3.2       16  -|-  777.60  —  793.6 


100 


0 


192  192 


showing  that,   in   compounding   a   16-4.05-3  2   mixture,   we   take    100  parts 
of  cream,  no  milk,  no  sugar  and  no  diluent. 

In  making  a  table  of  various  mixtures  from  this  formula, 
Moffitt  carries  the  calculations  to  0.1  per  cent,  i.  e.,  to  three 
decimal  places,  which  has  shown  results  within  0.04  per  cent 
of  perfect  accuracy  in  all  mixtures  in  which  he  has  calculated 
the  percentages  of  fat,  carbohydrates  and  proteins  from  the 
amounts  of  milk,  cream  and  sugar  used  in  compounding  such 
mixtures. 

By  the  table  from  this  formula  24  ounces  of  a  3-6-1  mixture 
require  3.5  ounces  of  milk,  and  3.6  ounces  of  cream  and  1.13 
ounces  of  milk-sugar.  Now  3.5  ounces  of  milk  and  3.6  ounces 
of  cream  contain  0.716  ounce  of  fat,  i.  e.,  2.98  per  cent  of  24 
ounces  (inaccurate  by  but  0.02  per  cent)  and  0.2377  ounce  of 
proteins,  i.  e.,  0.99  -f-  per  cent  of  24  ounces  (within  0.01  per  cent 


618  THE   DISEASES  OP    CHILDREN, 

of  absolute  accuracy),  and  these  amounts  of  milk  and  cream 
plus  the  added  sugar  total  in  all  1.4333  ounces  of  carbohydrates 
in  the  24  ounce  mixture  of  5.97  -|-  per  cent  (within  0.03  per 
cent). 

In  calculating  the  amounts  of  the  ingredients  in  24  ounces 
of  a  3.25-6-1.25  mixture  by  the  old  formula  we  arrive  at  an 
even  more  inaccurate  result  in  regard  to  the  proteins,  for  C  =  4 
ounces,  M^3.5  ounces  and  S  =  1.14  ounces,  and  in  24  ounces, 
4  ounces  of  cream  and  3.5  ounces  of  milk  give  3.25  per  cent 
fat  (accurate)  and  1.04  per  cent  of  proteins  (0.21  per  cent 
out  of  the  way),  and  these  amounts  of  cream  and  milk  with  the 
added  1.14  ounces  of  milk-sugar  give  6.08  per  cent  of  car- 
bohydrates (0.08  per  cent  off)  practically  a  3.25-6-1  mixture 
instead  of  a  3.25-6-1.25. 

By  this  table  24  ounces  of  a  3.25-6-1.25  mixture  require  5.328 
ounces  of  milk,  3.528  ounces  of  cream  and  1.056  ounces  of 
milk-sugar,  giving  3.24  per  cent  of  fat,  5.97  per  cent  of  car- 
bohydrates and  1.24  per  cent  of  proteins. 

The  greatest  inaccuracy  encountered  in  the  old  formula,  and 
in  our  table  as  well,  is  the  last  mixture  in  the  table,  viz.,  5-7- 
3.50.  By  the  old  formula  in  a  24-ounce  mixture  we  have  3 
ounces  of  cream,  18  ounces  of  milk  and  0.84  ounce  of  milk- 
sugar.  These  amounts  in  24  ounces  give  5  per  cent  of  fat 
(accurate),  7.38  per  cent  of  carbohydrates  (0.38  per  cent  off) 
and  3.02  per  cent  of  proteins  (0.48  off),  practically  a  5-7-3 
mixture  instead  of  a  5-7-3.50  mixture  as  far  as  the  proteins  are 
concerned. 

By  our  table  we  find  in  24  ounces  of  a  5-7-3.50  mixture  we 
require  of  milk  22.08  ounces,  cream  1.92  ounces  and  milk-sugar 
0.6  ounce.  These  amounts  give  of  fat  4.96  per  cent  (0.04  off), 
carbohydrates  6.96  per  cent  (0.04  off)  and  proteins  3.47  per 
cent   (but  0.03  off). 

Had  the  tables  been  carried  out  to  one  more  decimal  place 
all  calculations  would  have  been  within  0.01  per  cent  of  ab- 
solute accuracy. 

If  barley  water  or  other  cereal  water  is  used,  as  recommended 
by  many  to  assist  in  breaking  up  the  curd,  it,  too,  may  be 
added  in  the  quantity  desired  before  adding  the  water.     Since 


APPENDIX.  619 

barley  water  contains  of  fat  0.05  per  cent,  carbohydrates  1.63 
per  cent  and  proteins  0.09  per  cent  (Holt),  when  it  alone  is 
used  as  the  diluent,  a  reduction  should  be  made  in  the  car- 
bohydrate per  cent  of  the  formula;  e.  g.,  if  a  3-6-1  mixture  is 
desired  the  ingredients  of  a  3-5-1  mixture  should  be  used,  the 
percentage  of  the  carbohydrates  being  subsequently  raised  by 
the  addition  of  the  barley  water.  The  same  point  must  be 
observed  when  adding  the  various  dextrinizing  powders  to  the 
milk  mixtures.  The  dextrinizing  process  raises  the  sugar  con- 
tent about  2  per  cent,  so  if  a  3-6-1  mixture  were  desired,  the 
ingredients  of  a  3-4-1  mixture  are  dextrinized. 

In  the  modification  of  cow's  milk  by  any  formula  it  is  es- 
sential to  know  the  composition  of  the  milk  and  cream  used 
and  while  it  is  true  that  average  herd  milk  is  usually  4  per 
cent  and  gravity  usually  16  per  cent  it  is  advisable  to  make  the 
simple  fat  estimations  with  the  Babcock  centrifuge  from  time 
to  time,  for  if  the  fat  percentage  is  correct,  the  amounts  of  the 
other  ingredients  will  also  be  correct. 

CARE   OF  BABIES   IN  HOT  WEATHER. 

The  following  is  a  brochure  ^  issued  by  the  Babies '  Milk 
Fund  Association  of  Louisville  in  1908  on  the  Care  of  Babies 
in  Hot  Weather,  which  was  distributed  among  the  poor  and 
sent  to  every  new  mother  whose  confinement  was  reported  to 
the  city  health  office : 

TO  KEEP  THE  BABY  WELL. 

1.  Give  it  pure  air  day  and  night. 

2.  Give  it  no  food  but  mother's  milk,  or  milk  from  the  bottle, 
or  food  directed  by  a  physician. 

3.  Whenever  it  cries  or  is  fretful,  do  not  offer  it  food,  but 
give  it  ivater. 

4.  Be  sure  that  it  gets  enough  sleep — two  naps,  at  least,  dur- 
ing the  day. 

5.  Do  not  put  too  much  clothing  on  it. 

6.  Bathe  it  every  day  in  a  tub. 

7.  Don't  handle  it;  let  it  alone. 


^  Compiled  by  Letchworth   Smith,   M.D. 


620  THE   DISEASES   OF    CHILDREN. 

THE  CARE  OF  BABIES  IN  HOT  WEATHER. 

Clothing. — In  the  hot  weather  a  thin  gauze  shirt,  a  thin  mus- 
lin slip,  and  a  diaper.  On  the  hottest  days,  the  slip  and  diaper 
are  enough. 

Keep  the  baby  as  cool  and  comfortable  as  possible. 

As  soon  as  a  diaper  is  soiled  it  should  he  removed.  Place 
it  in  a  pail  with  a  cover  to  keep  the  odors  in  and  the  flies  out. 
Cover  it  with  water  and  wash  as  soon  as  possible  in  hot  water, 
to  which  a  little  soda  has  been  added.  The  diaper  should  be 
ivell  rinsed  and  thoroughly  dried  before  being  worn  again. 

At  least  once  a  week  all  diapers  should  be  thoroughly  hoiled. 

After  every  movement  the  parts  soiled  should  be  carefully 
cleansed  at  once.  Babies  often  get  sick  from  being  left  in  soiled 
diapers.  Never  think  of  putting  on  any  kind  of  baby  powder 
until  the  skin  is  clean  and  fairly  dry. 

If  the  skin  becomes  chafed  in  any  of  the  cracks  or  wrinkles 
apply  a  little  zinc  oxide  ointment. 

Bathing. — The  best  time  for  the  bath  is  just  before  a  feed- 
ing— if  possible,  at  the  same  time  each  day. 

The  baby  should  be  bathed  every  day  in  a  tub. 

The  water  should  be  slightly  warmer  than  its  own  body. 

Use  soap  that  will  not  irritate  its  skin. 

Do  not  bathe  within  an  hour  after  eating. 

In  very  hot  weather  finish  the  bath  with  a  little  cooler  water, 
and  give  three  or  four  general  spongings  during  the  day  with 
cool  water  containing  a  little  salt. 

If  the  child  suffers  from  "prickly  heat,"  bathe  the  affected 
skin  with  vinegar  and  water.  But  remember  that  a  roughened 
or  inflamed  skin  may  be  the  sign  of  an  infectious  disease  that 
needs  the  care  of  a  physician. 

Sleep. — After  the  bath  let  the  hahy  sleep  for  two  hours. 

Such  a  mid-day  nap  should  be  insisted  on  until  the  child  is 
a  year  old,  and  is  advisable  until  the  age  of  four. 

Cover  the  child  only  with  a  light  sheet  when  it  is  hot. 

Fresh  Air. — Fr'esh  air  is  very  necessary. 

Leave  the  windows  wide  open.  Never  put  a  child  to  sleep 
in  a  closed-up  room. 

Keep  it  out  of  doors  as  much  as  possible. 


APPENDIX.  621 

Avoid  the  sun  on  hot  days.  Keep  on  the  shady  side  of  the 
street,  or  in  shady  spots  in  the  park,  or  in  any  shady  spots 
where  the  air  is  fresh. 

Bed. — A  baby's  bed  should  be  flat,  firm,  clean  and  dry. 

Feather  pillows  are  bad  things  for  babies  to  lie  on,  especially 
in  the  summer. 

Feeding. — Every  mother  should  nurse  her  hahy,  if  she  can 
possibly  do  so. 

No  other  food  is  so  good  for  a  baby  as  mother's  milk.  . 

Of  the  babies  that  die  before  they  get  to  be  a  year  old,  nine 
out  of  every  ten  are  bottle  fed. 

Wash  the  nipple  with  cold  water  before  and  after  each 
nursing. 

The  mother  should  eat  plain,  well-cooked  food  and  should  see 
to  it  that  her  bowels  move  at  least  once  each  day.  Constipa- 
tion in  the  mother  is  bad  for  both  mother  and  child. 

She  should  be  careful  as  to  diet  and  habits  of  life.  Beer  and 
tea  are  harmful,  and  in  large  quantities  (two  pints  or  more 
daily)  may  be  very  injurious. 

Regular  Feeding. — Regularity  in  feeding  is  one  of  the  most 
important  things  in  the  care  of  a  baby.  Irregularity  in  feed- 
ing leads  to  over-feeding  in  most  cases,  and  often  causes  sick- 
ness, diarrhea  and  death. 

Feed  the  child  at  regular  intervals. 

Do  not  nurse  it  every  time  it  cries.  A  child  is  not  always 
hungry  when  it  cries,  but  it  will  eat  at  almost  any  time  that 
food  is  offered.  If  it  eats  before  its  stomach  is  ready  for  a 
fresh  supply  of  food,  it  may  become  sick. 

The  baby's  stomach  should  be  given  a  certain  length  of  tim£ 
to  digest  the  food  that  is  put  into  it.  It  should  then  have  a 
little  rest  before  it  is  called  on  to  digest  more  food.  If  it  is  not 
allowed  to  rest,  but  kept  at  work  constantly,  it  will  become 
exhausted,  and  that  means  that  the  baby  will  be  sick. 

If  a  baby  cries  between  feedings  give  it  a  drink  of  water  that 
has  been  boiled  and  then  cooled,  with  nothing  in  it. 

Even  very  young  nursing  babies  should  have  water  in  hot 
weather  between  feedings.  This  can  be  given  out  of  a  spoon 
or  a  perfectly  clean  nursing  bottle. 


622  THE  DISEASES  OF   CHILDREN. 

Breast  Feeding. — From  tlie  Third  Bay  to  the  Sixth  Week. 
— The  baby  should  be  nursed,  every  two  hours  during  the  day, 
6,  8,  10,  12,  2,  4,  6,  8,  and  should  be  nursed  only  twice  between 
10  p.  m.  and  6  a.  m.,  not  more  than  10  feedings  during  the  24 
hours.  The  baby  should  not  he  allowed  to  nurse  more  than  20 
minutes  at  a  time.  Nursing  longer  than  this  may  give  the 
stomach  more  than  it  can  properly  digest  before  time  for  the 
next  nursing. 

From  the  Sixth  Week  to  ths  Third  Month. — During  the  day 
six  nursings,  two  and  one-half  hours  apart,  at  6,  8.30,  11,  1.30, 
4  and  6.30.  From  that  time  on  till  morning  only  two  nursings 
should  be  allowed. 

From  the  Third  to  the  Sixth  Mmith.  The  nursings  should 
be  three  hours  apart  during  the  day,  at  6,  9,  12,  3,  6,  10,  with 
one  only  between  that  hour  and  6  o'clock  the  next  morning. 

From  the  Sixth  to  the  Ninth  Month. — The  times  of  feeding 
remain  the  same  but  the  night  feeding  shoidd  he  discontinued. 
The  child  may  wake  up  in  the  night,  but  should  be  given,  a 
drink  of  cooled,  boiled  water.  After  a  short  time,  if  it  is  well, 
it  will  sleep  through  the  night. 

From  the  Ninth  to  the  Twelfth  Month. — Nursings  three  and 
one-half   hours   apart.     Five   in   number.     None   at  night. 

Bottle  Feeding. — If  it  is  absolutely  impossible  for  a  mother 
to  nurse  her  baby,  it  may  be  possible  to  find  a  wet-nurse.  If 
this  cannot  be  done,  it  will  be  necessary  to  put  the  baby  on  the 
milk  of  some  animal. 

Cow's  milk  should  not  be  given  to  young  babies  much  under 
a  year  old  unless  it  is  diluted  with  certain  amounts  of  clean 
water  or  barley  water. 

The  hest  milk  you  can  get  is  not  too  good  for  the  baby. 

If  you  cannot  afford  to  drink  good  milk  yourself,  you  may 
be  able  to  get  along  without  it,  but  the  haby  needs  milk  and 
the  cleanest  milk  that  can  be  obtained.  Cheap  milk  is  not 
clean.  It  is  usually  keeping  milk  from  getting  dirty  that  makes 
it  expensive. 

All  babies  should  have  milk  that  is  clean  enough  to  be  cer- 
tified. 


APPENDIX.  623 

All  other  milk  should  he  heated  to  hoiling  as  soon  as  it  is 
purchased. 

To  keep  milk  sweet  get  it  from  the  milkman  whose  wagons, 
cans  and  horses  look  clean.  If  you  know  where  he  keeps  his 
cows,  go  and  see  if  he  keeps  them  clean. 

Get  your  milk  in  a  bucket  vrith  a  cover  so  that  the  flies  and 
dust  can  be  kept  out  of  it.  See  that  the  pail  is  well  washed, 
scalded  and  turned  upside  down  when  not  in  use. 

Ahvays  keep  the  milk  covered.     Always  keep  it  cold. 

If  you  cannot  get  ice,  keep  it  in  cold  running  water,  or  if 
this  is  not  possible,  wrap  a  damp  cloth  about  the  pail  and  set 
it  in  a  draft  of  air. 

Feeding  After  One  Year  of  Age. — Children  should  be  weaned 
when  12  months  old,  unless  the  weather  is  very  hot  or  a  physi- 
cian orders  otherwise. 

Wean  gradually. — At  first  substitute  one  bottle  for  one  nurs- 
ing.    After  a  few  days  give  two  bottles  a  day,  and  so  on. 

Bottle-fed  children  at  this  age  will-  require  more  than  milk, 
although  this  should  still  form  the  chief  part  of  their  food. 

During  the  second   year  most  children  are  badly   fed. 

Four  meals  a  day  should  be  given,  selected  from  the  fol- 
lowing : 

Soft-boiled  eggs;  strained  broths  of  beef,  mutton  and  chicken, 
containing  small  pieces  of  stale  or  toasted  bread;  stale  bread  or 
toast  with  milk;  hominy  (cooked  six  hours)  with  milk;  oatmeal 
or  rice  (cooked  three  hours)  with  milk;  cornmeal  (cooked  two 
hours)  wdth  milk;  farina  (cooked  one  hour)  with  milk.  The 
milk  should  be  boiled  unless  it  is  certified  milk.  Do  not  feed 
meat,  vegetables,  candy,  popcorn,  sugar,  bananas  or  anything 
else  unless  told  to  do  so  by  a  physician. 

Summer  Diarrhea. — When  the  baby  has  loose,  green  pas- 
sages, it  means  that  the  baby  is  sick  and  needs  medical  atten- 
tion. The  disease  is  mild  at  first  and  often  shows  no  other 
signs  of  illness  than  the  diarrhea.  There '  may  be  no  fever. 
Such  a  baby  often  becomes  dangerously  ill  in  a  short  time. 

The  simplest  case  of  vomiting  and  diarrhea  during  the  sum 
mer  should  not  be  neglected. 


624  THE  DISEASES  OP   CHILDREN. 

Stop  the  milk  at  once. 

Give  two  teaspoonfuls  of  castor  oil  and  feed  nothing  but 
barley  water  until  the  child  can  be  taken  to  a  doctor. 

Do  not  give  it  any  cordials  or  teas  or  "diarrhea  mixtures." 

Flies. — Remember  that  flies  are  dirty,  and  .often  carry 
disease. 

Keep  milk  and  other  food  covered  or  where  flies  cannot  get 
at  it. 

The  fly  that  falls  into  the  milk  bucket  may  have  just  come 
from  a  privy  used  by  a  person  having  typhoid  fever,  and  if 
so  the  one  drinking  the  milk  may  contract  the  disease. 

Keep  the  soiled  diapers  covered  so  that  flies  cannot  walk 
over  them  and  then  go  to  the  food  used  in  the  family. 

Windows  and  doors  should  be  screened,  especially  if  there 
is  a  baby  in  the  family. 

Give  the  Baby  a  Chance. — Do  not  get  it  in  the  habit  of  being 
held  by  its  mother  or  by  other  children. 

Most  babies  suffer  because  they  are  used  to  amuse  older 
people,  and  are  forced  to  laugh  or  are  tossed  about  and  excited 
when  they  need  to  be  resting  quietly. 

Get  it  early  into  the  habit  of  going  to  sleep  without  being 
rocked.  It  is  much  better  for  the  baby  to  learn  to  go  to  sleep 
without  this  motion,  and  to  have  it  do  so  will  save  much  time 
for  the  mother  and  enable  her  to  do  many  more  important 
things  in  the  way  of  keeping  things  clean,  and  of  resting  her- 
self. 

Children  often  cry  when  put  down  to  sleep.  If  they  are  left 
alone  and  not  handled  or  talked  to  they  will  soon  go  to  sleep. 

Crying  is  one  of  the  ways  in  which  babies  develop  their 
lungs — a  certain  amount  of  it  is  "natural,"  and  will  do  no 
harm  if  you  don 't  get  nervous  about  it. 

Try  to  get  people  to  leave  the  baby  alone.  Think  how  tired 
and  irritable  you  get  yourself  on  a  hot  day,  and  shield  the  baby 
as  much  as  possible  from  excitement  and  "attention." 

"Some  of  these  things  may  seem  like  extra  work,  but  they 
keep  the  baby  well,  and  it  is  far  less  trouble  to  keep  a  baby 
well  than  to  take  care  of  a  sick  baby." 

A  Mother. 


APPENDIX.  625 

MILK  MODIFICATIONS. 

Suggestive  Table  of  Feedings.  ^ 

Remove  the  top  9  ounces  from  1  quart  of  bottled  milk  into 
pitcher  or  bowl.  Of  this  milk  in  the  pitcher  or  bowl  use  4 
ounces  with  14  ounces  of  water  or  dextrinized  gruel  and  two 
level  tablespoonfuls  of  sugar.     (F.  2.7,  S.  6.,  P.   .7.) 

Divide  into  nine  feedings  of  2  ounces  each  in  separate  nurs- 
ing bottles,  and  feed  every  two  hours  during  the  day  and  twice 
at  night. 

TWO   TO   FOUR   WEEKS. 

Remove  the  top  9  ounces  from  1  quart  of  bottled  milk  into 
a  pitcher  or  bowl.  Of  this  milk  in  the  pitcher  or  bowl  use  7 
ounces  with  20  ounces  of  water  or  dextrinized  gruel  and  3  level 
tablespoonfuls  of  sugar.     (F.  3.,  S.  7.,  P.  1.) 

Divide  into  nine  feedings  of  2  to  3  ounces  each  in  separate 
nursing  bottles,  and  feed  every  two  hours  during  the  day  and 
twice  at  night. 

SECOND   MONTH, 

Remove  the  top  11  ounces  from  1  quart  of  bottled  milk  into 
a  pitcher  or  bowl.  Of  this  milk  in  the  pitcher  or  bowl  use  the 
entire  11  ounces  with  22  ounces  of  water  or  gruel  and  4  level 
tableepoonsfuls  of  sugar.     (F.  3.,  S.  7.,  P.  1.) 

Divide  into  eight  feedings  of  3  to  4  ounces  each  in  separate 
nursing  bottles,  and  feed  every  two  and  one-half  hours  during 
the  day  and  once  ^t  night. 

THIRD   MONTH. 

Remove  the  top  16  ounces  from  1  quart  of  bottled  milk  into 
a  pitcher  or  bowl.  Of  this  milk  in  the  pitcher  or  bowl  use 
14  ounces  with  18  ounces  of  water  or  gruel  and  4  level  table- 
spoonfuls of  sugar.     (F.  3.,  S.  7.,  P.  1.4.) 

Divide  into  seven  feedings  of  4  to  5  ounces  each  in  separate 
nursing  bottles,  and  feed  every  two  and  one-half  to  three  hours 
during  the  day  and  once  at  night. 


'Chapin:   Theory  and  Practice  of  Infant  Feeding.  '     t    ]i  \  ./,     | 


626  THE   DISEASES   OF   CHILDREN. 

POUR   TO   SIX   MONTHS. 

Remove  the  top  20  ounces  from  1  quart  of  bottled  milk  into 
a  pitcher  or  bowl.  Of  this  top  milk  in  the  pitcher  or  bowl  use 
the  entire  quantity  with  16  ounces  of  water  or  gruel  and  4  level 
tablespoonfuls  of  sugar.     (F.  3.,  S.  7.,  P.  2.) 

Divide  into  six  feedings  of  5  to  6  ounces  each  in  separate 
nursing  bottles,  and  feed  every  three  hours  during  the  day  and 
once  at  night. 

SEVEN   TO   NINE   MONTHS. 

Remove  the  top  24  ounces  from  each  2  quarts  of  bottled  milk 
into  a  pitcher  or  bowl.  Of  this  milk  in  the  pitcher  or  bowl 
use  33  ounces  with  15  ounces  of  water  or  gruel  and  4  level 
tablespoonfuls  of  sugar.     (F.  3.5,  S.  7.,  P.  2.2.) 

Divide  into  six  feedings  of  7  to  8  ounces  each  in  separate 
nursing  bottles,  and  feed  every  three  hours  during  the  day. 

TEN   TO   TWELVE   MONTHS. 

Remove  the  top  24  ounces  from  each  of  2  quart  bottles  of  milk 
into  a  pitcher  or  bowl.  Of  this  milk  in  the  pitcher  or  bowl 
use  40  ounces  with  8  ounces  of  water  or  gruel  and  4  level  table- 
spoonfuls of  sugar.     (F.  4.,  S.  7.,  P.  2.6.) 

Divide  into  five  feedings  of  8  to  10  ounces  each  in  separate 
nursing  bottles,  and  feed  every  three  and  one-half  hours. 

TWELVE   TO   FOURTEEN    MONTHS. 

Whole  milk,  or,  if  not  digested  well,  add  one-fourth  gruel. 
Amount  in  the  bottle  from  9  to  12  ounces.  Chicken,  mutton 
or  beef  broths,  in  same  amount,  may  also  be  given. 

SUGGESTIVE  FORMUL-ffi   (HOLT). 

First  Series  of  Formulae.     Fat  to  proteids,  3:1. 

Primary  Formulae.  Ten  per  cent  milk  or  fat  10  per  cent, 
sugar  4.3  per  cent,  proteids  3.3  per  cent.  Obtained  (1)  as 
upper  portion  of  bottled  milk,  or  (2)  equal  parts  milk  and 
(16  per  cent)   cream. 


APPENDIX. 


627 


DERIVED  FORMULAS,   GIVING  QUANTITIES  FOR  TWENTY-OUNCE 
MIXTURES. 


■H. 

• 

Fat 
per 
cent 

Sugar 
per 
cent 

Pro- 
teids 
per 
cent 

I. 

■  Milk  sugar,    1  oz.  ] 
Lime-water,     1  oz. 
Water  qs.  to  20  oz, 

►  with  2  oz. 

of  10% 

milk  = 

1.00 

5.00 

0.33 

II 

"     "         20  oz. 

"     3oz. 

"  10% 

"    ^=: 

1.50 

5.50 

0.50 

III 

"     "         20  oz. 

"     4  oz. 

"  10% 

it     

2.00 

6.00 

0.66 

IV 

"     "        .20  oz. 

"     5  oz. 

•'  10% 

"    =^ 

2.50 

6.00 

0.83 

V 

"     "         20  oz. 

"     6  oz. 

"  10% 

a     , , 

3.00 

6.00 

1.00 

VI 

"     "         20  oz. 

"     7  oz. 

"   10% 

^= 

3.50 

6.50 

1.16 

Seeond  Series  of  Formulfe.     Fat  to  proteids,  2:1. 

Primary  Formula.  Seven  per  cent  milk  or  fat  7  per  cent, 
sugar  4.40  per  cent,  proteids  3.50  per  cent.  Obtained  (1)  as 
upper  portion  of  bottled  milk,  or  (2)  by  using  three  parts  milk 
and  one  part   (16  per  cent)   cream. 

DERIVED  FORMULAS,   GIVING  QUANTITIES  FOR  TWENTY-OUNCE 
MIXTURES. 


Pro- 
teids 
per 
cent 


] 


II 

III 

IV 

V 

VI 

VII 

VIII 


Milk  sugar,  1  oz. 
Lime-water,  1  oz. 
Water  qs.  to  20  oz. 
20  oz. 


with  3  oz.  of  7%  milk: 


20  oz. 
20  oz. 
20  oz. 
20  oz. 
20  oz. 
20  oz. 

iMilk  sugar,  f  oz. 
Lime-water  1  oz. 
Water  qs.  to  20  oz. 


4  oz. 

5  oz. 
Goz. 
7oz. 
8oz. 
9oz. 

10  oz. 

12  oz. 


7% 
7% 
7% 
7% 
7% 
7% 
7% 


7%     "     — 


Fat 

Sugar 

per 

per 

cent 

cent 

1.00 

5.50 

1.40 

5.75 

1.75 

6.00 

2.10 

6.00 

2.50 

6.50 

2.80 

6.50 

3.15 

7.00 

3.50 

7.00 

4.00 

7.00 

0.50 

0.70 
0.87 
1.05 
1.25 
1.40 
1.55 
1.75 

2.00 


Third  Series  of  Formulae. — Fat  to  proteids,  8:7. 

Primary  Formula. — Plain  milk:  Fat  4  per  cent,  sugar  4.5 
per  cent,  proteids  3.5  per  cent.  (When  using  Jersey  or  Alder- 
ney  milk  add  one-fourth  water.) 


628  THE   DISEASES   OF    CHILDREN. 

DERIVED  FORMULAS,   GIVING   QUANTITIES  FOR  TWENTY-OUNCE 
MIXTURES. 


• 

Fat 
per 
cent 

Sugar 
per 
cent 

Pro- 
teids 
per 
cent 

I, 

Milk  sugar,    1  oz.  ] 
Lime-water,    1  oz.     with 
Water  qs.  to  20  oz. 

5  oz.  plain 

milk  := 

1.00 

6.00 

0.87 

II 

"      "        20  oz. 

6  oz.       " 

"     P=. 

1.20 

6.50 

1.00 

III 

"      "        20  oz. 

8  oz. 

"      = 

1.60 

6.50 

1.40 

IV 

"      "        20  oz. 

10  oz.       " 

"      = 

2.00 

7.00 

1.75 

V. 

Milk  sugar,    i  oz.  ] 
Lime-water,     1  oz.  |-      " 
Water  qs.  to  20  oz.  J 

12  oz.       " 

«      __ 

2.40 

5.00 

2.10 

VI 

"      "        20  oz. 

14  oz.       " 

«      

2.80 

5.50 

2.50 

VII 

"      "        20  oz. 

16  oz. 

"^^ 

3.20 

5.50 

2.80 

SUGGESTIVE  FORMUL-ffi  (KERLEY). 

Kerley  ^  suggests  the  following  formulai  by  diluting  the  top 
16  ounces  milk ;  this  will  analyze,  fat,  7  per  cent,  sugar  3.2  per 
cent,  proteids  3.2  per  cent. 

FROM   THE   THIRD   TO   THE   TENTH   DAY. 

Ounces. 
Milk     (top    16    oz.) 3  Approximate  Percentage  Equivalent. 

Lme-water \  Fat    1.3 

Milk   sugar 1  Sugar   6.6 

Boiled  water   to  make  ....  16  Total  proteid 0.6 

Ten  feedings  in  twenty-four  hours;  1  to  \\  ounces  at  each  feeding. 

FROM   TENTH   TO  THE  TWENTY-FIRST   DAY. 

Milk  (top  16  oz.)    6        Fat    1.75 

Lime-water \\      Sugar 6.8 

Milk   sugar \\       Total  proteid 0.3 

Water  to  make 24 

Nine  to  ten  feedings  in  twenty-four  hours;   li  ounces  at  each  feeding. 

FROM    THE   THIRD   TO   THE   SIXTH    WEEK. 

Milk    (top   16  oz.)    10         Fat   2.2 

Lime-water 22i       Sugar    7.0 

Milk  sugar   2         Total  proteid    1.0 

Water  to  make    32 

Eight  to  nine  feedings  in  twenty-four  hours;  2  to  3  ounces  each  feeding. 


»  Kerley :   Treatment  of  Diseases  of  Children. 


APPENDIX.  629 

FROM  THE  SIXTH  WEEK  TO  THE  THIRD  MONTH. 
Ounces. 

Milk   (top  16  OZ. )     12  Approximate  Percentage  Equivalent. 

Milk  sugar 2         Fat    2.6 

Lime-water    3         Sugar 7.2 

Water  to  make 32         Total  proteid    1.2 

Seven  to  eight  feedings  in  twenty-four  hours;  2^  to  4  ounces  at  feeding. 

FROM  THE  THIRD   TO  THE   FIFTH   MONTH. 

After  this  age  two  bottles  of  milk  are  required,  16  ounces  being  taken 
from  the  top  of  each  bottle  and  mixed.  At  this  time  a  cereal  jelly  is  usu- 
ally added  to  the  food. 

Milk  (top  16  OZ.) 18         Fat    3.15 

Milk  sugar   2         Sugar    6.4 

Lime-water 4         Total  proteid   1.4 

Water  to  make   40 

Six  feedings  in  twenty-four  hours;  4  to  5  ounces  at  each  feeding. 

FROM   FIFTH   TO   THE   SEVENTH    MONTH. 

Milk  (top  16  OZ.) 21         Fat    3.50 

Milk  sugar   2         Sugar 6.4 

Lime-water 5         Total  proteid 1.8 

Water  to  make 42 

Six  feedings  in  twenty-four  hours;  5  to  7  ounces  at  each  feeding. 

FROM   THE  SEVENTH   TO   THE   NINTH   MONTH. 

Milk  (top  16  OZ.)    27         Fat    3.9 

MHk  sugar 2 J         Sugar    7.0 

Lime-water   6         Total  proteid    1.8 

Water  to  make    48 

Five  to  six  feedings  in  twenty-four  hours;  7  to  9  ounces  at  each  feeding. 

FROM   THE  NINTH   TO  THE   TWELFTH   MONTH. 

Milk  (top  16  OZ.)    35         Fat 4.3 

Milk  sugar    2J       Sugar    6.5 

Lime-water   6         Total  proteid    2.0 

Water  to  make 56 

The  following  are  formula;  as  used  by  the  Babies'  Milk  Fund 
Association  adapted  milk  laboratory: 

Per  cent.  Ounces. 

Fat    1  W' hole  milk    8 

Sugar    6  Lime-water 2 

Proteid    1  10  per  cent  sugar  solution 11 

Water    11 


630 


THE   DISEASES   OP    CHILDREN. 


8  BOTTLES; 
Per  cent. 

Fat 2 

Sugar   7 

Proteid     1 


4  OUNCES. 

Ounces. 

Top  9  ounces  milk 4| 

Bottom  or  skim  milk 3 

10  per  cent  sugar  solution 17i 

Water    3 


Fat  ... 
Sugar  . 
Proteid 


7  BOTTLES; 

3 

.......   6 

1 


4  OUNCES  EACH. 

Top  12  ounces  milk 6 

Bottom  or  skim  milk 4 

10  per  cent  sugar  solution 17 

Water     8 


7  BOTTLES;    5  OUNCES  EACH. 

Fat   3.5        Top  12  ounces  milk 6 

Sugar   7  Bottom  or  skim  milk 18 

Proteid 2  10  per  «ent  sugar  solution 13 

Water    3 


6   BOTTLES;    7 

Fat    1.3 

Sugar   6.6 

Proteid 0.6 


Fat  ... 
Sugar  . 
Proteid 


Fat  ... 
Sugar  . 
Proteid 


2.2 

7 
1 


2.6 

7 

1 


Fat   3.1 

Sugar  7 

Proteid    1.6 


Fat   3.93 

Sugar   7 

Proteid 1.8 


Fat   4.3 

Sugar   7.3 

Proteid 2.0 


OUNCES   EACH. 

Top  16  ounces  from  quart 3 

Lime-water J 

Milk  sugar 1 

Water  q.  s 16 

Top  16  ounces   10 

Lime-water 2^ 

Milk  sugar 2 

Water  q.  s 32 

Top  16  ounces   12 

Milk  sugar 2 

Lime-water 3 

Water  q.  «s 32 

Top  16  ounces  from  two  quarts.  .21 

Milk  sugar  2^ 

Lime-water    5 

Water  q.  s 42 

Top  16  ounces  from  two  quarts.  .27 

Lime-water 6 

Milk  sugar 2^ 

Water  q'.  s 48 

Top  16  ounces  from  two  quarts.  .35 

Milk  sugar  3 

Lime-water 6 

Water  q.  s 56 


APPENDIX. 

HESS  REFRIGERATOR. 


631 


Dr.  Alfred  Hess  ^  of  New  York  has  suggested  an  inexpensive 
home-made  refrigerator  which,  if  it  could  be  put  into  general 


Fig.  105. — Hess  home-made  refrigerator.  Horizontal  section.  M,  milk  container, 
I,  broken  ice;  C,  can  for  holding  ice;  T,  tin  or  galvanized  iron  cylinder  to 
prevent  sawdust,  S,  from  falling  into  space  when  can  is  removed  for  pur- 
pose of   emptying   water. 


Fig.  106. — Hess  home-made  refrigerator.  Vertical  section.  S,  sawdust,  excelsior 
or  other  cheap  non-conductor  of  heat;  T,  cylinder  of  tin  or  galvanized  iron; 
C,  can  in  which  is  placed  the  milk  jar,  M,  surrounded  by  broken  ice,  I ;  news- 
papers  nailed   to   lid   of   case. 

use  among  the  poor,  would  prevent  many  cases  of  milk  poison- 
ing among  children  who  are  fed  milk  teeming  with  bacteria, 
because  it  has  not  been  kept  cold. 


'  Journal   American   Medical   Association,    vol.    li,    no.    4. 


632  THE   DISEASES   OP    CHILDREN, 

The  illustrations  given  on  page  631  show  the  construction  of 
the  box. 

METHODS  AND  STANDARDS  FOR   THE  PRODUCTION 
AND  DISTRIBUTION  OF  ''CERTIFIED  MILK.''^ 

Adopted  by  the  American  Association  of  Medical  ]\Iilk  Com- 
missions, May  1,  1912. 

Certified  milk  is  the  product  of  dairies  operated  in  accordance 
with  accepted  rules  and  regulations  formulated  by  authorized 
medical  milk  commissions  to  insure  its  purity  and  adaptability 
for  infants  and  invalids. 

The  need  for  such  a  milk  was  experienced  primarily  by  those 
engaged  in  the  conservation  of  the  life  and  health  of  infants. 
As  a  result  there  was  formulated  in  1892  a  plan  whereby  cer- 
tified milk  would  be  produced  by  a  dairyman  under  the  con- 
trol of  a  medical  milk  commission  designated  by  a  representa- 
tive medical  society. 

The  first  rules  designed  for  this  purpose  were  those  con- 
tained in  an  agreement  entered  into  by  a  medical  milk  commis- 
sion and  the  dairyman  concerned.^ 

The  rules  contained  in  the  original  agreement  mentioned  rep- 
resented the  essential  requirements  for  the  production  of  cer- 
tified milk.  Following  this  precedent,  other  commissions  were 
organized,  which,  in  1906,  became  federated  into  a  national  as- 
sociation known  as  the  American  Association  of  Medical  Milk 
Commissions. 

A  fundamental  ob.ject  of  this  association  was  to  bring  about 
the  uniformity  of  standards  and  their  perfection.  This  result 
has  been  reached  by  the  adoption  from  time  to  time  of  definite 

1  At  the  fifth  annual  meeting  of  the  American  Association  of  Medicnl  Milk  Com- 
missions, held  in  Philadelphia  May  25,  1911,  a  committee  was  appointed  to  revise 
the  manual  of  working  methods  and  standards  for  the  guidance  of  medical  milk 
commissions  in  the  supervision  of  the  production  and  distribution  of  certified  milk. 
The  committee  consisted  of  Dr.  .1.  W.  Kerr  (chairman).  Dr.  S.  McC.  Hamill.  and  Dr. 
Henry  L.  Coit.  This,  their  report,  was  ndopted  at  the  sixth  annual  meeting,  held  at 
Louisville,  Ky.,  May  1,  1912,  as  the  working  methods  and  standards  of  the  associa- 
tion. The  association  recommends  them  to  component  commissions  as  ideal  and  to 
be  as  closely  approximated  as  possible.  The  report  includes  a  statement  concerning 
the  certified-milk  movement,  as  well  as  the  revised  methods  and  standards,  and  is  pub- 
lished for  the  information  of  those  interested  in  the  improvement  of  public  milk  sup- 
plies. 

Reprint  from  the  Public  Health  Reports,   vol.  xxvii,   no.  24,   .Tune   14.   1912. 

2  Bui.  56,  Hvgienic  Laboratorv,  Public  Health  and  Marine  Hospital  Service,  p. 
615. 


APPENDIX.  633 

standards  relating  to  the  veterinary  inspection  of  herds  and 
farms,  the  medical  inspection  of  employees  handling  the  milk, 
and  the  bacteriological  and  chemical  examinations  as  to  quality 
and  purity.  The  requirements  with  respect  to  these  four  topics 
have  been  previously  reported  upon  by  committees  and  adopted 
by  the  association,  and  at  its  last  annual  meeting  provision  was 
made  for  their  further  revision   and   amplification. 

ORGANIZATION  OF  MEDICAL  MILK  COMMISSIONS. 

The  medical  milk  commission  is  appointed  by  a  representa- 
tive medical  society,  and  acts  under  its  auspices  and  for  it, 
to  encourage  the  production  of  milk  of  the  highest  possible 
standards  of  purity.  No  commission  should  be  considered  as 
certifying  milk  that  does  not  conform  to  the  standards  adopted 
from  time  to  time  by  the  Association  of  Medical  Milk  Com- 
missions. The  commission  should  include  at  least  five  mem- 
bers or  a  number  sufficient  to  become  responsible  for  and  to 
carry  on  the  following  divisions  of  work:  (a)  The  hygiene  of 
the  dairy,  as  it  relates  to  the  production  and  distribution  of  the 
milk;  (6)  the  veterinary  supervision  of  the  herd;  (c)  the  med- 
ical supervision  of  the  employees;  (d)  the  chemical  and  bac- 
teriological examinations  of  the  milk. 

DUTIES   OF  THE   COMMISSION. 

After  its  organization  the  commission  should  designate  a 
veterinarian,  a  physician,  a  chemist,  and  a  bacteriologist  to  en- 
force its  methods  and  standards  which  shall  be  the  prevailing 
methods  and  standards  of  the  American  Association  of  Med- 
ical Milk  Commissions,  and  these  officers  should  be  required  to 
render  regular  reports  of  their  inspections  and  examinations. 
A  uniform  written  agreement  should  then  be  entered  into  with 
any  dairyman  who  is  desirous  of  undertaking  the  production 
of  certified  milk  and  the  investigation  of  whose  plant  shows 
it  to  be  properly  equipped  for  such  purpose.  Such  agreement 
shall  require  the  observance  of  the  methods  and  standards  here- 
inafter mentioned. 

Upon  receipt  of  favorable  reports  from  the  several  experts 


634  THE   DISEASES   OP    CHILDREN. 

and  committees  which  have  made  the  investigations,  the  dairy- 
man should  be  authorized,  in  accordance  with  the  terms  of  the 
agreement,  to  employ  the  term  ''certified  milk,"  and  he  shall 
be  required  to  attach  to  all  containers  of  any  character  used 
in  distributing  the  milk  produced  under  the  agreement  a  cer- 
tificate or  seal  bearing  the  term  "certified  milk,"  the  name  of 
the  medical  milk  commission  certifying  it,  and  the  day  or  date 
of  production  of  the  milk  contained  therein. 

HYGIENE  OF  THE  DAIRY. 

UNDER     THE     SUPERVISION     AND     CONTROL    OF     THE     VETERINARIAN 

1.  Pastures  or  Paddocks. — Pastures  or  paddocks  to  which 
the  cows  have  access  shall  be  free  from  marshes  or  stagnant 
pools,  crossed  by  no  stream  which  might  become  dangerously 
contaminated,  at  sufficient  distances  from  offensive  conditions 
to  suffer  no  bad  effects  from  them,  and  shall  be  free  from  plants 
which  affect  the  milk  deleteriously. 

2.  Surroundings  of  Buildings. — The  surroundings  of  all  build- 
ings shall  be  kept  clean  and  free  from  accumulations  of  dirt, 
rubbish,  decayed  vegetable  or  animal  matter  or  animal  waste, 
and  the  stable  yard  shall  be  well  drained. 

3.  Location  of  Buildings. — Buildings  in  which  certified  milk 
is  produced  and  handled  shall  be  so  located  as  to  insure  proper 
shelter  and  good  drainage,  and  at  sufficient  distance  from  other 
buildings,  dusty  roads,  cultivated  and  dusty  fields,  and  all  other 
possible  sources  of  contamination;  provided,  in  the  'case  of 
unavoidable  proximity  to  dusty  roads  or  fields,  the  exposed 
side  shall  be  screened  with  cheesecloth. 

4.  Construction  of  Stables. — The  stables  shall  be  constructed 
so  as  to  facilitate  the  prompt  and  easy  removal  of  waste  prod- 
ucts. The  floors  and  platforms  shall  be  made  of  cement  or 
other  nonabsorbent  material,  and  the  gutters  of  cement  only. 
The  floors  shall  be  properly  graded  and  drained,  and  the  ma- 
nure gutters  shall  be  from  6  to  8  inches  deep  and  so  placed  in 
relation  to  the  platform  that  all  manure  will  drop  into  them. 

5.  The  inside  surface  of  the  walls  and  all  interior  construc- 
tion shall  be  smooth,  with  tight  joints,  and  shall  be  capable  of 


APPENDIX.  635 

shedding  water.  The  ceiling  shall  be  of  smooth  material  and 
dust-tight.  All  horizontal  and  slanting  surfaces  which  might 
harbor  dust  shall  be  avoided. 

6.  Drinking  and  Feed  Troughs. — Drinking  troughs  or  basins 
shall  be  drained  and  cleaned  each  day,  and  feed  troughs  and 
mixing  floors  shall  be  kept  in  a  clean  and  sanitary  condition. 

7.  Stanchions. — Stanchions  when  used  shall  be  constructed 
of  iron  pipes  or  hardwood,  and  throat  latches  shall  be  pro- 
vided to  prevent  the  cows  from  lying  down  between  the  time 
of  cleaning  and  the  time  of  milking. 

8.  Ventilation. — The  cow  stables  shall  be  provided  with  ade- 
quate ventilation  either  by  means  of  some  approved  artificial 
device,  or  by  the  substitution  of  cheesecloth  for  glass  in  the 
windows,  each  cow  to  be  provided  with  a  minimum  of  600 
cubic  feet  of  air  space. 

9.  Windows. — A  sufficient  number  of  windows  shall  be  in- 
stalled and  so  distributed  as  to  provide  satisfactory  light  and 
a  maximum  of  sunshine ;  2  feet  square  of  window  area  to  each 
600  cubic  feet  of  air  space  to  represent  the  minimum.  The 
coverings  of  such  windows  shall  be  kept  free  from  dust  and  dirt. 

10.  Exclusion  of  flies,  etc. — All  necessary  measures  should 
be  taken  to  prevent  the  entrance  of  flies  and  other  insects,  and 
rats  and  other  vermin  into  all  the  buildings. 

11.  Exclusion  of  Animals  from  the  Herd. — No  horses,  hogs, 
dogs,  or  other  animals  or  fowls  shall  be  allowed  to  come  in  con- 
tact with  the  certified  herd  either  in  the  stables  or  elsewhere. 

12.  Bedding. — No  dusty  or  moldy  hay  or  straw,  bedding 
from  horse  stalls,  or  other  unclean  materials  shall  be  used  for 
bedding  the  cows.  Only  bedding  which  is  clean,  dry,  and  ab- 
sorbent may  be  used,  preferably  shavings  or  straw. 

13.  Cleaning  Stable  and  Disposal  of  Manure. — Soiled  bed- 
ding and  manure  shall  be  removed  at  least  twice  daily,  and  the 
floors  shall  be  swept  and  kept  free  from  refuse.  Such  cleaning 
shall  be  done  at  least  one  hour  before  the  milking  time.  ]\Ia- 
nure,  when  removed,  shall  be  drawn  to  the  field  or  temporarily 
stored  in  containers  so  screened  as  to  exclude'  flies.  Manure 
shall  not  be  even  temporarily  stored  within  300  feet  of  the 
barn  or  dairy  building. 


636  THE   DISEASES   OP    CHILDREN. 

14.  Cleaning  of  Cows. — Each  cow  in  the  herd  shall  be 
groomed  daily,  and  no  manure,  mud,  or  filth  shall  be  allowed  to 
remain  upon  her  during  milking;  for  cleaning,  a  vacuum  ap- 
paratus is  recommended. 

15.  Clipping. — Long  hairs  shall  be  clipped  from  the  udder 
and  flanks  of  the  cow,  and  from  the  tail  above  the  brush.  The 
hair  on  the  tail  shall  be  cut  so  that  the  brush  may  be  well  above 
the  ground. 

16.  Cleaning  of  Udders. — The  udders  and  teats  of  the  cow 
shall  be  cleaned  before  milking;  they  shall  be  washed  with  a 
cloth  and  water,  and  dry  wiped  with  another  clean  sterilized 
cloth — a  separate  cloth  for  drying  each  cow. 

17.  Feeding. — All  foodstuffs  shall  be  kept  in  an  apartment 
separate  from  and  not  directly  communicating  with  the  cow 
barn.  They  shall  be  brought  into  the  barn  only  immediately 
before  the  feeding  hour,  which  shall  follow  the  milking. 

18.  Only  those  foods  shall  be  used  which  consist  of  fresh, 
palatable,  or  nutritious  materials,  such  as  will  not  injure  the 
health  of  the  cows  or  unfavorably  affect  the  taste  or  character 
of  the  milk.  Any  dirty  or  moldy  food  or  food  in  a  state  of 
decomposition  or  putrefaction  shall  not  be  given. 

19.  A  well-balanced  ration  shall  be  used,  and  all  changes  of 
food  shall  be  made  slowly.  The  first  few  feedings  of  grass, 
alfalfa,  ensilage,  green  corn,  or  other  green  feeds  shall  be  given 
in  small  rations  and  increased  gradually  to  full  ration. 

20.  Exercise. — All  dairy  cows  shall  be  turned  out  for  exer- 
cise at  least  2  hours  in  each  24  in  suitable  weather.  Exercise 
yards  shall  be  kept  free  from  manure  and  other  filth. 

21.  Washing  of  Hands. — Conveniently  located  facilities  shall 
be  provided  for  the  milkers  to  wash  in  before  and  during  milk- 
ing. 

22.  The  hands  of  the  milkers  shall  be  thoroughly  washed 
with  soap,  water,  and  brush  and  carefully  dried  on  a  clean 
towel  immediately  before  milking.  The  hands  of  the  -milkers 
shall  be  rinsed  with  clean  water  and  carefully  dried  before  milk- 
ing each  cow.  The  practice  of  moistening  the  hands  with  milk 
is  forbidden. 

23.  Milking  Clothes. — Clean  overalls,  jumper,  and  cap  shall 


APPEkDix.  637 

be  worn  during  milking.  They  shall  be  washed  or  sterilized 
each  day  and  used  for  no  other  purpose,  and  when  not  in  use 
they  shall  be  kept  in  a  clean  place,  protected  from  dust  and  dirt. 

24.  Things  to  be  Avoided  by  Milkers. — While  engaged  about 
the  dairy  or  in  handling  the  milk  employees  shall  not  use 
tobacco  nor  intoxicating  liquors.  They  shall  keep  their  fingers 
away  from  their  nose  and  mouth,  and  no  milker  shall  permit 
his  hands,  fingers,  lips,  or  tongue  to  come  in  contact  with  milk 
intended  for  sale. 

25.  During  milking  the  milkers  shall  be  careful  not  to  touch 
anything  but  the  clean  top  of  the  milking  stool,  the  milk  pail, 
and  the  cow's  teats. 

26.  Milkers  are  forbidden  to  spit  upon  the  walls  or  floors  of 
stables,  or  upon  the  walls  or  floors  of  milk  houses,  or  into  the 
water  used  for  cooling  the  milk  or  washing  the  utensils. 

27.  Fore  Milk. — The  first  streams  from  each  teat  shall  be 
rejected,  as  this  fore  milk  contains  large  numbers  of  bacteria. 
Such  milk  shall  be  collected  into  a  separate  vessel  and  not 
milked  onto  the  floors  or  into  the  gutters.  The  milking  shall 
be  done  rapidly  and  quietly,  and  the  cows  shall  be  treated 
kindly. 

28.  Milk  and  Calving  Period. — Milk  from  all  cows  shall  be 
excluded  for  a  period  of  45  days  before  and  7  days  after  par- 
turition. 

29.  Bloody  and  Stringy  Milk. — If  milk  from  any  cow  is 
bloody  and  stringy  or  of  unnatural  appearance,  the  milk  from 
that  cow  shall  be  rejected  and  the  cow  isolated  from  the  herd 
until  the  cause  of  such  abnormal  appearance  has  been  deter- 
mined and  removed,  special  attention  being  given  in  the  mean- 
time to  the  feeding  or  to  possible  injuries.  If  dirt  gets  into 
the  pail,  the  milk  shall  be  discarded  and  the  pail  washed  be- 
fore it  is  used. 

30.  Make-up  of  Herd. — No  cows  except  those  receiving  the 
same  supervision  and  care  as  the  certified  herd  shall  be  kept  in 
the  same  barn  or  brought  in  contact  with  them. 

31.  Employees  Other  than  Milkers. — The  requirements  for 
milkers,  relative  to  garments  and  cleaning  of  hands,  shall  apply 
to  all  other  persons  handling  the  milk,  and  the  children  unat- 


638  THE  DISEASES   OF    CHILDREN. 

tended  by  adults  shall  not  be  allowed  in  the  dairy  nor  in  the 
stable  during  milking. 

32.  Straining  and  Strainers. — Promptly  after  the  milk  is 
drawn  it  shall  be  removed  from  the  stable  to  a  clean  room  and 
then  emptied  from  the  milk  pail  to  the  can,  being  strained 
through  strainers  made  of  a  double  layer  of  finely  meshed 
cheesecloth  or  absorbent  cotton  thoroughly  sterilized.  Several 
strainers  shall  be  provided  for  each  milking  in  order  that  they 
may  be  frequently  changed. 

33.  Dairy  Building. — ^A  dairy  building  shall  be  provided 
which  shall  be  located  at  a  distance  from  the  stable  and  dwell- 
ing prescribed  by  the  local  commission,  and  there  shall  be  no 
hogpen,  privy,  or  manure  pile  at  a  higher  level  or  within  300 
feet  of  it. 

34.  The  dairy  building  shall  be  kept  clean  and  shall  not  be 
used  for  purposes  other  than  the  handling  and  storing  of  milk 
and  milk  utensils.  It  shall  be  provided  with  light  and  ventila- 
tion, and  the  floors  shall  be  graded  and  water-tight. 

35.  The  dairy  building  shall  be  well  lighted  and  screened  and 
drained  through  well-trapped  pipes.  No  animals  shall  be  al- 
lowed therein.  No  part  of  the  dairy  building  shall  be  used  for 
dwelling  or  lodging  purposes,  and  the  bottling  room  shall  be 
used  for  no  other  purpose  than  to  provide  a  place  for  clean  milk 
utensils  and  for  handling  the  milk.  During  bottling  this  room 
shall  be  entered  only  by  persons  employed  therein.  The  bot- 
tling room  shall  be  kept  scrupulously  clean  and  free  from  odors. 

36.  Temperature  of  Milk. — Proper  cooling  to  reduce  the  tem- 
perature to  45°  F.  shall  be  used,  and  aerators  shall  be  so  situ- 
ated that  they  can  be  protected  from  flies,  dust,  and  odors.  The 
milk  shall  be  cooled  immediately  after  being  milked,  and  main- 
tained at  a  temperature  between  35°  and  45°  F.  until  delivered 
to  the  customer. 

37.  Seaiing  of  Bottles. — Milk,  after  being  cooled  and  bottled, 
shall  be  immediately  sealed  in  a  manner  satisfactory  to  the  com- 
mission, but  such  seal  shall  include  a  sterile  hood  which  com- 
pletely covers  the  lip  of  the  bottle. 

38.  Cleaning  and  Sterilizing  of  Bottles. — The  dairy  building 
shall  be  provided  with  approved  apparatus  for  the  cleansing  and 


APPENDIX.  639 

sterilizing  of  all  bottles  and  utensils  used  in  milk  production. 
All  bottles  and  utensils  shall  be  thoroughly  cleaned  by  hot  water 
and  sal  soda,  or  equally  pure  agent,  rinsed  until  the  cleaning 
water  is  thoroughly  removed,  then  exposed  to  live  steam  or  boil- 
ing water  at  least  20  minutes,  and  then  kept  inverted  until  used, 
in  a  place  free  from  duSt  and  other  contaminating  materials. 

39.  Utensils. — All  utensils  shall  be  so  constructed  as  to  be 
easily  cleaned.  The  milk  pail  should  preferably  have  an  ellip- 
tical opening  5  by  7  inches  in  diameter.  The  cover  of  this  pail 
should  be  so  convex  as  to  make  the  entire  interior  of  the  pail 
visible  and  accessible  for  cleaning.  The  pail  shall  be  made  of 
heavy  seamless  tin,  and  with  seams  which  are  flushed  and  made 
smooth  by  solder.  Wooden  pails,  galvanized-iron  pails,  or  pails 
made  of  rough,  porous  materials,  are  forbidden.  All  utensils 
used  in  milking  shall  be  kept  in  good  repair. 

40.  Water  Supply. — The  entire  water  supply  shall  be  abso- 
lutely free  from  contamination,  and  shall  be  sufficient  for  all 
dairy  purposes.  It  shall  be  protected  against  flood  or  surface 
drainage,  and  shall  be  conveniently  situated  in  relation  to  the 
milk  house. 

41 .  Privies,  etc.,  in  Relation  to  Water  Supply. — Privies,  pig- 
pens, manure  piles,  and  -all  other  possible  sources  of  contamina- 
tion shall  be  so  situated  on  the  farm  as  to  render  impossible  the 
contamination  of  the  water  supply,  and  shall  be  so  protected  by 
use  of  screens  and  other  measures  as  to  prevent  their  becoming 
breeding  grounds  for  flies. 

42.  Toilet  Rooms. — Toilet  facilities  for  the  milkers  shall  be 
provided  and  located  outside  of  the  stable  or  milk  house.  These 
toilets  shall  be  properly  screened,  shall  be  kept  clean,  and  shall 
be  accessible  to  wash  basins,  water,  nail  brush,  soap  and  towels, 
and  the  milkers  shall  be  required  to  wash  and  dry  their  hands 
immediately  after  leaving  the  toilet  room. 

Transportation. 

43.  In  transit  the  milk  packages  shall  be  kept  free  from  dust 
and  dirt.  The  wagon,  trays,  and  crates  shall  be  kept  scrupu- 
lously clean.  No  bottles  shall  be  collected  from  houses  in  which 
communicable  diseases  prevail,  unless  a  separate  wagon  is  used 


640  THE   DISEASES   OF    CHILDREN. 

and  under  conditions  prescribed  by  the  department  of  health 
and  the  medical  milk  commission. 

44.  All  certified  milk  shall  reach  the  consumer  within  30  hours 
after  milking. 

Veterinary  Supervision  of  the  Herd. 

45.  Tuberculin  Test. — The  herd  shall  be  free  from  tuber- 
culosis, as  shown  by  the  proper  application  of  the.  tuberculin  test, 
The  test  shall  be  applied  in  accordance  with  the  rules  and  regu- 
lations of  the  United  States  Government,  and  all  reactors  shall 
be  removed  immediately  from  the  farm.^ 

46.  No  new  animals  shall  be  admitted  to  the  herd  without  first 
having  passed  a  satisfactory  tuberculin  test,  made  in  accordance 
with  the  rules  and  regulations  mentioned ;  the  tuberculin  to  be 
obtained  and  applied  only  by  the  ofificial  veterinarian  of  the 
commission. 

47.  Immediately  following  the  application  of  the  tuberculin 
test  to  a  herd  for  the  purpose  of  eliminating  tuberculous  cattle, 
the  cow  stable  and  exercising  yards  shall  be  disinfected  by  the 
veterinary  inspector  in  accordance  with  the  rules  and  regula- 
tions of  the  United  States  Government.^ 

48.  A  second  tuberculin  test  shall  follow  each  primary  test 
after  an  interval  of  six  months,  and  shall  be  applied  in  accord- 
ance with  the  rules  and  regulations  mentioned.  Thereafter, 
tuberculin  tests  shall  be  reapplied  annually,  but  it  is  recom- 
mended that  the  retests  be  applied  semiannually. 

49.  Identification  of  Cows. — Each  dairy  cow  in  each  of  the 
certified  herds  shall  be  labeled  or  tagged  with  a  number  or  mark 
which  will  permanently  identify  her. 

50.  Herd-book  Record. — Each  cow  in  the  herd  shall  be  reg- 
istered in  a  herd  book,  which  register  shall  be  accurately  kept 
so  that  her  entrance  and  departure  from  the  herd  and  her  tuber- 
culin testing  can  be  identified. 

51.  A  copy  of  this  herd-book  record  shall  be  kept  in  the  hands 
of  the  veterinarian  of  the  medical  milk  commission  under  which 
the  dairy  farm  is  operating,  and  the  veterinarian  shall  be  made 
responsible  for  the  accuracy  of  this  record. 


1  See   Circular   of  Instructions   issued  hy   the   Bureau   of  Animal   Industry   for  mak- 
ing tuberculin  tests  and  for  the  disinfection   of  premises. 


APPENDIX.  641 

52.  Dates  of  Tuberculin  Tests. — The  dates  of  the  annual 
tuberculin  tests  shall  be  definitely  arranged  by  the  medical  milk 
commission,  and  all  of  the  results  of  such  tests  shall  be  recorded, 
by  the  veterinarian  and  regularly  reported  to  the  secretary  of 
the  medical  milk  commission  issuing  the  certificate. 

53.  The  results  of  all  tuberculin  tests  shall  be  kept  on  file  by 
each  medical  milk  commission,  and  a  copy  of  all  such  tepts  shall 
be  made  available  to  the  American  Association  of  Medical  Milk 
Commissions  for  statistical  purposes. 

54.  The  proper  designated  officers  of  the  American  Associa- 
tion of  Medical  Milk  Commissions  should  receive  copies  of  reports 
of  all  of  the  annual,  semiannual,  and  other  official  tuberculin 
tests  which  are  made  and  keep  copies  of  the  same  on  file  and 
compile  them  annually  for  the  use  of  the  association. 

55.  Disposition  of  Cows  Sick  with  Diseases  other  than  Tuber- 
culosis.— Cows  having  rheumatism,  leukorrhea,  inflammation 
of  the  uterus,  severe  diarrhea,  or  diseases  of  the  udder,  or  cows 
that  from  any  other  cause  may  be  a  menace  to  the  herd  shall  be 
removed  from  the  herd,  placed  in  a  building  separate  from  that 
which  may  be  used  for  the  isolation  of  cows  with  tuberculosis, 
unless  such  building  has  been  properly  disinfected  since  it  was 
last  used  for  this  purpose.  The  milk  from  such  cows  shall  not 
be  used,  nor  shall  the  cows  be  restored  to  the  herd  until  permis- 
sion has  been  given  by  the  veterinary  inspector  after  a  careful 
physical  examination. 

56.  Notification  of  Veterinary  Inspector. — In  the  event  of 
the  occurrence  of  any  of  the  diseases  just  described  between  the 
visits  of  the  veterinary  inspector,  or  if  at  any  time  a  number 
of  cows  become  sick  at  one  time  in  such  a  way  as  to  suggest  the 
outbreak  of  a  contagious  disease  or  poisoning,  it  shall  be  the  duty 
of  the  dairyman  to  withdraw  such  sickened  cattle  from  the  herd, 
to  destroy  their  milk,  and  to  notify  the  veterinary  inspector  by 
telegraph  or  telephone  immediately. 

57.  Emaciated  Cows. — Cows  that  are  emaciated  from  chronic 
diseases  or  from  any  cause  that  in  the  opinion  of  the  veterinary 
inspector  may  endanger  the  quality  of  the  milk,  shall  be  re- 
moved from  the  herd. 


642  THE  DISEASES   OF    CHILDREN. 

Bacteriological  Standards. 

58.  Bacterial  Counts. — Certified  milk  shall  contain  less  than 
10,000  bacteria  per  cubic  centimeter  when  delivered.  In  case  a 
count  exceeding  10,000  bacteria  per  cubic  centimeter  is  found, 
daily  counts  shall  be  made,  and  if  normal  counts  are  not  restored 
within  10  days  the  certificate  shall  be  suspended. 

59.  Bacterial  counts  shall  be  made  at  least  once  a  week. 

60.  Collection  of  Samples. — The  samples  to  be  examined 
shall  be  obtained  from  milk  as  offered  for  sale  and  shall  be  taken 
by  a  representative  of  the  milk  commission.  The  samples  shall 
be  received  in  the  original  packages,  in  properly  iced  contain- 
ers, and  they  shall  be  so  kept  until  examined,  so  as  to  limit  as 
far  as  possible  changes  in  their  bacterial  content. 

61.  For  the  purpose  of  ascertaining  the  temperature,  a  sepa- 
rate original  package  shall  be  used,  and  the  temperature  taken 
at  the  time  of  collecting  the  sample,  using  for  the  purpose  a 
standardized  thermometer  graduated  in  the  centigrade  scale. 

62.  Interval  Between  Milking  and  Plating. — The  examina- 
tions shall  be  made  as  soon  after  collection  of  the  samples  as 
possible,  and  in  no  case  shall  the  interval  between  milking  and 
plating  the  samples  be  longer  than  40  hours. 

63.  Plating. — The  packages  shall  be  opened  with  aseptic 
precautions  after  the  milk  has  been  thoroughly  mixed  by  vig- 
orously reversing  and  shaking  the  container  25  times. 

64.  Two  plates  at  least  shall  be  made  for  each  sample  of  milk, 
and  there  shall  also  be  made  a  control  of  each  lot  of  medium 
and  apparatus  used  at  each  testing.  The  plates  shall  be  grown 
at  37°  C.  for  48  hours. 

65.  In  making  the  plates  there  shall  be  used  agaragar  media 
containing  1.5  per  cent  agar  and  giving  a  reaction  of  1.0  to 
phenolphthalein. 

The  following  is  the  method  recommended  by  a  committee  of  the  Amer- 
ican Public  Healtli  Association  for  the  making  of  the  media,  modified,  how- 
ever, as  to  the  agar  content  and  reaction  to  conform  to  the  requirements 
specified  in  section  65 : 

1.  Boil  15  grams  of  thread  agar  in  500  cc.  of  water  for  half  an  hour  and 
make  up  weight  to  500  g.  or  digest  for  10  minutes  in  the  autoclave  at  110° 
C.     Let  this  cool  to  about  60°  C. 


APPENDIX  643 

2.  Infuse  500  g.  finely  chopped  lean  beef  for  24  hours  with  its  own  weight 
of  distilled  water  in  the  refrigerator. 

3.  Make  up  any  loss  by  evaporation. 

4.  Strain  infusion  through  cotton  flannel,  using  pressure. 

5.  Weigh  filtered  infusion. 

6.  Add  Witte's  peptone,  2  per  cent. 

7.  Warm  on  water  bath,  stirring  until  peptone  is  dissolved  and  not  al- 
lowing temperature  to  rise  above  60°  C. 

8.  To  the  500  grams  of  meat  infusion  (with  peptone)  add  500  g.  of  the 
2  per  cent  agar,  keeping  the  temperature  below  60°  C. 

9.  Heat  over  boiling  water  (or  steam)  bath  30  minutes. 

10.  Restore  weight  lost  by  evaporation. 

11.  Titrate  after  boiling  one  minute  to  expel  carbolic  acid. 

12.  Adjust  reaction  to  final  point  desired  -j-  1  by  adding  normal  sodium 
hydrate. 

13.  Boil  two  minutes  over  free  flame,  constantly  stirring. 

14.  Restore  weight  lost  by  evaporation. 

15.  Filter  through  absorbent  cotton  or  coarse  filter  paper,  passing  the 
filtrate  througli  the  filter  repeatedly  until  clear. 

16.  Titrate  and  record  the  final  reaction. 

17.  Tube  (10  cc.  to  a  tube)  and  sterilize  in  autoclave  one  hour  at  15 
pounds  pressure  or  in  the  streaming  steam  for  20  minutes  on  three  succes- 
sive days. 

66.  Samples  of  milk  for  plating  shall  be  diluted  in  the  pro- 
portion of  1  part  of  milk  to  99  parts  of  sterile  water;  shake  25 
times  and  plate  1  cc.  of  the  dilution. 

The  committee  on  bacterial  milk  analyses  of  the  American  Public  Health 
Association  in  Part  IV  of  its  report  presented  details  with  respect  to  plat- 
ing apparatus  and  technique  in  part  as  follows: 

Plating  apparatus. — For  plating  it  is  best  to  have  a  water  bath  in  which 
to  melt  the  media  and  a  water-jacketed  water  bath  for  keeping  it  at  the  re- 
quired temperature;  a  wire  rack  which  should  fit  both  the  water  baths  for 
holding  the  media  tubes;  a  thermometer  for  recording  the  temperature  of 
the  water  in  the  water- jacketed  bath,  sterile  1  cc.  pipettes,  sterile  Petri 
dishes,  and  sterile  dilution  watdr  in  measured  quantities. 

Dilutions. — Ordinary  potable  water,  sterilized,  may  be  used  for  dilutions. 
Occasionally  spore  forms  are  found  in  such  water  which  resist  ordinary 
-autoclave  sterilization;  in  such  cases  distilled  water  may  be  used  or  the 
autoclave  pressure  increased.  With  dilution  water  in  8-ounce  bottles  cali- 
brated for  99  cubic  centimeters  ...  all  the  necessary  dilutions  may  be 
made. 

Short,  wide-mouthed  '"blakes"  or  wide-mouthed  French  square  bottles  are 
more  easily  handled  and  more  economical  of  space  than  other  forms  of 
bottles  or  flasks. 


644  THE  DISEASES  OF   CHILDREN. 

Eight-ounce  bottles  are  the  best,  as  the  required  amount  of  dilution  water 
only  about  half  fills  them,  leaving  room  for  sliaking.  Long-fiber  nonab- 
sorbent  cotton  should  be  used  for  plugs.  It  is  well  to  use  care  in  selecting 
cotton  for  this  purpose  to  avoid  short-fiber  or  dusty  cotton,  which  give  a 
cloud  of  lint-like  particles  on  shaking.  Bottles  .  .  .  should  be  filled  a  little 
over  the  99  cc.  .  .  .  to  allow  for  less  during  sterilization. 

Pipettes. — Straight  sides  1  cc.  pipettes  are  more  easily  handled  than 
those  with  bulbs;  they  may  be  made  from  ordinary  three-sixteenths  inch 
glass  tubing  and  should  be  about  10  inches  in  length. 

Plating  technique. — The  agar  after  melting  should  be  kept  in  the  water- 
jacketed  water  bath  between  40°  C.  and  45°  C.  for  at  least  15  minutes  be- 
fore using  to  make  sure  that  the  agar  itself  has  reached  the  temperature  of 
the  surrounding  water.  If  used  too  warm,  the  heat  may  destroy  some  of 
the  bacteria  or  retard  their  growth. 

Shake  the  milk  sample  25  times,  then  with  a  sterile  pipette  transfer  1  cc. 
to  the  first  dilution  water  and  rinse  the  pipette  by  drawing  dilution  water 
to  the  mark  and  expelling;  this  gives  a  dilution  of  1  to  100. 

.  .  .  Then  with  a  sterile  pipette  transfer  1  cc.  to  the  Petri  dish,  using 
care  to  raise  the  cover  only  as  far  as  necessary  to  insert  the  end  of  the 
pipette. 

Take  the  tube  of  agar  from  the  water  bath,  wipe  the  water  from  outside 
the  tube  with  a  piece  of  cloth,  remove  the  plug,  pass  the  mouth  of  the  tube 
through  a  flame,  and  pour  the  agar  into  the  plate,  using  the  same  care  as 
before  to  avoid  exposure  of  the  plate  contents  to  the  air. 

Carefully  and  thoroughly  mix  the  agar  and  diluted  milk  in  the  Petri  dish 
by  a  rotary  motion,  avoiding  the  formation  of  air  bubbles  or  slopping  the 
agar,  and  after  allowing  the  agar  to  harden  for  at  least  15  minutes  at 
room   temperature,  place  the  dish  bottom  down  in   the   incubator. 

Plating  should  always  be  done  in  a  place  free  from  dust  or  currents  of 
air. 

In  order  that  colonies  may  have  sufficient  food  for  proper  development 
10  cc.  of  agar  shall  be  used  for  each  plate. 

67.  Determination  of  Taste  and  Odor  of  Milk.— After  the 
plates  have  been  prepared  and  placed  in  the  incubator,  the  taste 
and  odor  of  the  milk  shall  be  determined  after  warming  the  milk 
to  100°  F.^ 

68.  Counts. — The  total  number  of  colonies  on  each  plate 
should  be  counted,  and  the  results  expressed  in  multiples  of  the 
dilution  factor.  Colonies  too  small  to  be  seen  with  the  naked 
eye  or  with  slight  magnification  shall  not  be  considered  in  the 
count. 


1  Should  it  -be  deemed  desirable  and  necessary  to  conduct  tests  for  sediment,  the 
presence  of  special  bacteria,  or  the  number  of  leucocytes,  the  methods  adopted  by  the 
committee  of  the  American  Public  Health  Association  should  be  followed. 


APPENDIX.  645 

69.  Records  of  Bacteriologic. Tests. — The  results  of  all  bac- 
terial tests  shall  be  kept  on  file  by  the  secretary  of  each  com- 
mission, copies  of  which  should  be  made  available  annually  for 
the  use  of  the  American  Association  of  Medical  Milk  Commissions. 

Chemical  Standards  and  Methods. 

The  methods  that  must  be  followed  in  carrying  out  the  chem- 
ical investigations  essential  to  the  protection  of  certified  milk  are 
so  complicated  that  in  order  to  keep  the  fees  of  the  chemist  at 
a  reasonable  figure,  there  must  be  eliminated  from  the  examina- 
tion those  procedures  which,  whilst  they  might  be  helpful  and 
interesting,  are  in  no  sense  necessary. 

For  this  reason  the  determination  of  the  water,  the  total  solids 
and  the  milk  sugar  is  not  required  as  a  part  of  the  routine  ex- 
amination. 

70.  The  chemical  anaylses  shall  be  made  by  a  competent  chem- 
ist designated  by  the  medical  milk  commission. 

71.  Method  of  Obtaining  Samples. — The  samples  to  be  ex- 
amined by  the  chemist  shall  have  been  examined  previously  by 
the  bacteriologist  designated  by  the  medical  milk  commission,  as 
to  temperature,  odor,  taste,  and  bacterial  content. 

72.  Fat  Standards. — The  fat  standard  for  certified  milk  shall 
be  4  per  cent,  with  a  permissible  range  of  variation  of  from 
3.5  to  4.5  per  cent. 

73.  The  fat  standard  for  certified  cream  shall  be  not  less  than 
18  per  cent. 

74.  If  it  is  desired  to  sell  higher  fat-percentage  milks  or 
creams  as  certified  milks  or  creams,  the  range  of  variation  for 
such  milks  shall  be  0.5  per  cent  on  either  side  of  the  advertised 
percentage  and  the  range  of  variations  for  such  creams  shall  be 
2  per  cent  on  either  side  of  the  advertised  percentage. 

75.  The  fat  content  of  certified  milks  and  creams  shall  be  de- 
termined at  least  once  each  month. 

76.  The  methods  recommended  for  this  purpose  are  the  Bab- 
cock  (a),  the  Leffmann-Beam  (&),  and  the  Gerber  (c). 

(o)  Babcock  test. — The  Babcock  test  is  based  on  the  fact  that  strong 
sulphuric  acid  will  dissolve  the  nonfatty  solid  constituents  of  milk,  and 
thus  enable  the  fat  to  separate  on  standing.  It  can  be  conducted  by  any 
of  the  Babcock  outfits  which  are  purchasable  in  the  market. 


646  THE   DISEASES   OF    CHILDREN. 

"The  test  is  made  by  placing  in  the  special  test  bottle  8  grams  (17.0 
cc.)  of  milk.  To  this  is  added,  from  a  pipette,  burette,  or  measuring  bottle, 
17.5  cc.  commercial  sulphuric  acid  of  a  specific  gravity  of  1.82  to  1.83. 
The  contents  of  the  bottle  are  carefully  and  thoroughly  mixed  by  a  rotary 
motion.  The  mixture  becomes  brown  and  heat  is  generated.  The  test 
bottle  is  now  placed  in  a  properly  balanced  centrifuge  and  whirled  for  5 
minutes  at  a  speed  of  from  800  to  1,200  revolutions  per  minute.  -Hot 
water  is  then  added  to  fill  the  bottle  to  the  lower  part  of  the  neck,  after 
wliich  it  is  again  whirled  for  two  minutes.  Now,  enough  hot  water  is 
added  to  float  the  column  of  fat  into  the  graduated  portion  of  the  neck 
of  the  bottle,  and  the  whirling  is  repeated  for  a  minute.  The  amount  of 
fat  is  read  while  the  neck  of  the  bottle  is  still  hot.  The  reading  is  from 
the  upper  limits  of  the  meniscus.  A  pair  of  calipers  is  of  assistance  in 
measuring  the  column  of  fat."  (Jensen's  Milk  Hygiene,  Leonard  Pear- 
son's translation.) 

(b)  Leffmann-Beam  test. — The  distinctive  feature  is  the  use  of  fusel  oil, 
the  effect  of  which  is  to  produce  a  greater  difference  in  surface  tension  be- 
tween the  fat  and  the  liquid  in  which  it  is  suspended,  and  thus  promote  its 
readier  separation.  This  effect  has  been  found  to  be  heightened  by  the 
presence  of  a  small  amount  of  hydrochloric  acid. 

The  test  bottles  have  a  capacity  of  about  30  cc.  and  are  provided  with  a 
graduated  neck,  each  division  of  which  represents  9.1  per  cent  by  weight 
of  butter  fat. 

Fifteen  centimeters  of  the  milk  are  measured  inlo  the  bottle,  3  cc.  of 
a  mixture  of  equal  parts  of  aniyl  alcohol  and  strong  hydrochloric  acid  added 
and  mixed.  Tlien  9  cc.  of  concentrated  sulpliuric  acid  is  added  in  por- 
tions of  about  1  cc;  after  each  addition  the  liquids  are  mixed  by  giving 
the  bottle  a  gyratory  motion.  If  the  fluid  has  not  lost  all  of  its  milky 
color  by  this  treatment,  a  little  more  concentrated  acid  must  be  added. 
The  neck  of  the  bottle  is  now  immediately  filled  at  about  the  zero  point 
with  one  part  sulphuric  acid  and  two  parts  water,  well  mixed  just  before 
using.  Both  the  liquid  in  the  bottle  and  the  diluted  acid  must  be  hot. 
The  bottle  is  then  placed  at  once  m  the  centrifugal  machine;  after  rota- 
tion from  one  to  two  minutes,  the  fat  will  collect  in  the  neck  of  the  bottle 
and  the  percentage  may  be  read  off. 

(c)  Gerber's  test. — This  test  is  applied  as  follows:  The  test  bottles  are 
put  into  the  stand  with  the  mouths  uppermost;  then,  with  the  pipette 
designed  for  the  purpose,  or  with  an  automatic  measurer,  10  cc.  of  sul- 
phuric acid  are  filled  into  the  test  bottle,  care  being  taken  not  to  allow 
any  to  come  in  contact  with  tlie  neck.  The  few  drops  remaining  in  the 
tip  of  the  pipett«  should  not  be  blown  out.  Then  11  cc.  of  milk  are 
measured  with  the  proper  pipette  and  allowed  to  flow  slowly  onto  the 
acid,  so  that  the  two  liquids  mi.x  as  little  as  possible.  Finally,  the  amji 
alcohol  is  added.  (It  is  important  to  use  the  reagents  in  the  proper  order, 
M'hicli  is — sulphuric  acid,  milk,  amyl  alcohol.  If  the  sulphuric  acid  is  fol- 
lowed by  amyl  alcohol  and  the  milk  last,  then  the  result  is  sometimes  in- 


APPENDIX.  647 

correct.)  A  rubber  stopper,  which  must  not  be  damaged,  is  then  fitted  into 
the  mouth  of  the  test  bottle,  and  the  contents  are  well  shaken,  the  thumb 
being  kept  on  the  stopper  to  prevent  it  coming  out.  As  a  considerable 
amount  of  heat  is  generated  by  the  action  of  the  sulphuric  acid  on  the 
milk,  the  test  bottle  should  be  wrapped  in  a  cloth. 

The  shaking  of  the  sample  must  be  done  thoroughly  and  quickly,  and 
the  test  bottle  inverted  several  times,  so  that  the  liquid  in  the  neck  be- 
comes thoroughly  mixed.  By  pressing  in  the  rubber  stopper  the  height 
of  the  liquid  can  be  brought  to  about  the  zero  point  on  the  scale. 

If  only  a  few  samples  have  to  be  analyzed  and  the  room  is  warm,  the 
test  bottles  can  be  put  into  the  centrifuge  without  any  preliminary  heat- 
ing, otherwise  the  test  bottles  must  be  warmed  for  a  few  minutes  (not 
longer)  in  the  water  bath  at  a  temperature  of  60°  to  65°  C  When  the 
temperature  rises  higher  than  this,  say  above  70°  C,  the  rubber  stopper  is 
liable  to  be  blown  out  of  the  test  bottle.  After  the  test  bottles  have  been 
heated  thej'  are  arranged  symmetrically  in  the  centrifuge  and  whirled  for 
3  to  4  muiutes  at  a  speed  of  about  1,000  revolutions  per  minute.  When 
the  centrifuge  has  a  heating  arrangement  attached  to  it,  the  preliminary 
warming  is  not,  of  course,  necessary.  When  the  test  bottles  are  taken  out 
of  the  centrifuge,  they  are  again  placed  in  the  water  bath  at  a  tempera- 
ture of  60°  to  65°  C,  and  left  there  for  several  minutes  before  being  read; 
where  the  centrifuge  is  heated,  the  tubes  can  be  read  off  as  taken  from 
the  centrifuge. 

By  carefully  screwing  in  tlie  rubber  stopper,  or  even  by  pressing  it,  the 
lower  limit  of  tlie  fat  column  is  brought  onto  one  of  the  main  divisions  of 
the  scale,  and  then,  by  holding  the  test  bottle  against  the  light  the  height 
of  the  column  of  fat  can  be  accurately  ascertained.  The  lowest  point  of 
the  meniscus  is  taken  as  the  level  when  reading  the  upper  surface  of  the 
fat  in  a  sample  of  whole  milk,  and  the  middle  of  the  meniscus  for  separated 
milk. 

If  the  column  of  fat  is  not  clear  and  sharply  defined,  the  sample  must 
be  again  whirled  in  the  centrifuge. 

Each  division  on  the  scale  is  equivalent  to  0.1  per  cent,  so  it  is  very 
easy  to  read  to  0.05  per  cent  or,  with  a  lens,  to  0.025  per  cent.  If  the 
number  which  is  read  off'  is  multiplied  by  0.1,  then  the  percentage  quantity 
of  fat  in  the  milk  is  obtained;  e.  g.,  if  the  number  on  the  scale  was  36.5, 
then  the  percentage  of  fat  is  3.65.  (Milk  and  Dairy  Products,  Barthel; 
translated  by  Goodwin,  p.  71.) 

77.  Before  condemning  samples  of  milk  which  have  fallen  out- 
side the  limits  allowed,  the  chemist  shall  have  determined,  by 
control  ether  extractions,  that  his  apparatus  and  his  technique 
are  reliable. 

78.  Protein  Standard. — The   protein  standard  for  certified 


648  THE   DISEASES   OF    CHILDREN. 

milk  shall  be  3.50  per  cent  with  a  permissible  range  of  variation 
of  from  3  to  4  per  cent. 

79.  The  protein  standard  for  certified  cream  shall  correspond 
to  the  protein  standard  for  certified  milk. 

80.  The  protein  content  shall  be  determined  only  when  any 
special  consideration  seems  to  the  medical  milk  commission  to 
make  it  desirable. 

81.  It  shall  be  determined  by  the  Kjeldahl  method,  using  the 
Gunning  or  some  other  reliable  modification,  and  employing  the 
factor  6.25  in  reckoning  the  protein  from  the  nitrogen. 

Kjeldahl  method. — Five  cubic  centimeters  of  milk  are  measured  carefully 
into  a  flat-bottom  800  cc.  Jena  flask,  20  cc.  of  concentrated  sulphuric  acid 
(C.  P.;  sp.  gr.,  1.84)  are  added,  and  0.7  gram  of  mercuric  oxid  (or  its 
equivalent  in  metallic  mercury)  ;  the  mixture  is  then  heated  oyer  direct 
flame  until  it  is  straw-colored  or  perfectly  white;  a  few  crystals  of  potas- 
sium permanganate  are  now  added  till  the  color  of  the  liquid  remains 
green.  All  the  nitrogen  in  the  milk  has  then  been  converted  into  the 
form  of  ammonium  sulphate.  After  cooling,  200  cc.  of  ammonia-free  dis- 
tilled water  are  added,  20  cc.  of  a  solution  of  potassium  sulphide  (con- 
taining 40  grams  sulphide  per  liter),  and  a  fraction  of  a  gram  of  powdered 
zinc.  A  quantity  of  semi-normal  HCl  solution  more  than  sufficient  to 
neutralize  the  ammonia  obtained  in  the  oxidation  of  the  milk  is  now  care- 
fully measured  out  from  a  delicate  burette  (divided  into  I/^q  cc.)  into  an 
Erlenmeyer  flask  and  the  flask  connected  with  a  distillation  apparatus.  At 
the  other  end  the  Jena  flask  containing  the  watery  solution  of  the  am- 
monium sulphate  is  connected,  after  adding  50  cc.  of  a  concentrated  soda 
solution  (1  pound  "pure  potash"  dissolved  in  500  cc.  of  distilled  water  and 
allowed  to  settle)  ;  the  contents  of  the  Jena  flask  are  now  heated  to  boil- 
ing, and  the  distillation  is  continued  for  40  minutes  to  an  hour,  until  all 
ammonia  has  been  distilled  over. 

The  excess  of  acid  in  the  Erlenmeyer  receiving  flask  is  then  accurately 
titrated  back  by  means  of  a  tenth-normal  standard  ammonia  solution,  using 
a  cochineal  solution  as  an  indicator.  From  the  amount  of  acid  used  the 
per  cent  of  nitrogen  is  obtained;  and  from  it  the  per  cent  of  casein  and 
albumen  in  the  milk  by  multiplying  by  6.25.  The  amount  of  nitrogen  con- 
tained in  the  chemicals  used  is  determined  by  blank  experiments  and  de- 
ducted from  the  nitrogen  obtained  as  described.  (Farrington  and  Woll, 
Testing  Milk  and  Its  Products,  p.  221.) 

82.  Coloring  Matter  and  Preservatives. — All  certified  milks 
and  creams  shall  be  free  from  adulteration,  and  coloring  mat- 
ter and  preservatives  shall  not  be  added  thereto, 


APPENDIX.  649 

83.  Tests  for  the  detection  of  added  coloring  matter  shall  be 
applied  whenever  the  color  of  the  milk  or  cream  is  such  as  to 
arouse  suspicion. 

Test  for  coloring  matter. — The  presence  of  foreign  coloring  matter  in 
milk  is  easily  shown  by  shaking  10  cc.  of  the  milk  with  an  equal  quantity 
of  ether;  on  standing,  a  clear  ether  solution  will  rise  to  the  surface;  if 
artificial  coloring  matter  has  been  added  to  the  milk,  the  solution  will  be 
yellow  colored,  the  intensity  of  the  color  indicating  the  quantity  added; 
natural  fresh  milk  will  give  a  colorless  ether  solution.  (Testing  Milk  and 
its  Products,  Farrington  and  Woll,  p.  244.) 

84.  Tests  for  the  detection  of  formaldehyde,  borax,  and 
boracic  acid  shall  be  applied  at  least  once  each  month.  Occa- 
sionally application  of  tests  for  the  detection  of  salicylic  acid, 
benzoic  acid,  and  the  benzoates  are  also  recommended. 

Test  for  the  detection  of  formaldehyde.— Five  cubic  centimeters  of  milk 
is  measured  into  a  white  porcelain  dish,  and  a  similar  quantity  of  water 
added;  10  cc.  of  HCl,  containing  a  trace  of  FejCla  is  added,  and  the  mix- 
ture is  heated  very  slowly.  If  formaldehyde  is  present,  a  violet  color  will 
be  formed.      (Testing  Milk  and  Its  Products,  Farrington  and  Woll,  p.  249.) 

Test  for  boracic  acid  ( borax,  borates,  preservaline,  etc. ) . — One  hundred 
cubic  centimeters  of  milk  are  made  alkaline  with  a  soda  or  potash  solu- 
tion, and  then  evaporated  to  dryness  and  incinerated.  The  ash  is  dissolved 
in  water,  to  which  a  little  hydrochloric  acid  has  been  added,  and  the  solu- 
tion filtered.  A  strip  of  turmeric  paper  moistened  with  the  filtrate  will 
be  colored  reddish  brown  when  dried  at  100°  C.  on  a  watch  glass,  if  boracic 
acid  is  present. 

If  a  little  alcohol  is  poured  over  the  ash  to  which  concentrated  sulphuric 
acid  has  been  added,  and  fire  is  set  to  the  alcohol,  after  a  little  this  will 
burn  with  a  yellowish-green  tint,  especially  noticeable  if  the  ash  is  stirred 
with  a  glass  rod  and  when  the  flame  is  about  to  go  out. —  (Testing  Milk 
and  Its  Products,  FarVington  anu  Woll,  p.  247.) 

Test  for  salicylic  acid  {salicylates,  etc.) — ^Twenty  cubic  centimeters  of 
milk  are  acidulated  with  sulphuric  acid  and  shaken  with  ether;  the  ether 
solution  is  evaporated,  and  the  residue  treated  with  alcohol  and  a  little 
iron-chlorid  solution ;  a  deep  violet  color  will  be  obtained  in  the  presence 
of  salicylic  acid. —  (Testing  Milk  and  Its  Products,  Farrington  and  Woll, 
p.  248.) 

Test  for  benzoic  acid. — Two  hundred  and  fifty  to  five  hundred  cubic  cen- 
timeters of  milk  are  made  alkaline  with  a  few  drops  of  lime  or  baryta 
water,  and  then  evaporated  to  about  a  quarter  of  the  milk.  Powdered  gyp- 
sum is  stirred  into  the  remaining  liquid  until  a  paste  is  formed,  which 
is  then  dried  on  the  water  bath.     The  gypsum  only  serves  to  hasten  the 


650  THE  DISEASES   OP    CHILDREN. 

drying,  and  powdered  pumice  stone  or  sand  can  be  used  equally  well.  When 
the  mass  is  dry,  it  is  finely  powdered  and  moistened  with  dilute  sulphuric 
acid  and  shaken  out  three  or  four  times  with  about  twice  the  volume  of  50 
per  cent  alcohol,  in  which  benzoic  acid  is  easily  soluble  in  the  cold,  the 
fat  only  being  dissolved  to  a  very  slight  extent  or  not  at  all.  The  acid  al- 
coholic liquid  from  the  various  extractions,  wliich  contains  milk  sugar 
and  inorganic  salts  in  addition  to  the  benzoic  acid,  is  neutralized  with 
baryta  water  and  evaporated  to  a  small  bulk.  Dilute  sulphuric  acid  is 
again  added,  and  the  liquid  shaken  out  with  small  quantities  of  ether. 
On  evaporation  of  the  ether,  the  benzoic  acid  is  left  behind  in  almost  pure 
state,  the  only  impurities  being  small  quantities  of  fat  or  ash. 

The  benzoic  acid  which  is  obtained  is  dissolved  in  a  small  quantity  of 
warm  water,  a  drop  of  sodium  acetate  and  neutral  ferric  chloride  added, 
and  the  red  precipitate  of  benzoate  of  iron  indicates  the  presence  of  the 
acid.      (Milk  and  Dairy  Products,  Barthel,  translated  by  Goodwin,  p.  121.) 

85.  Detection  of  Heated  Milk. — Certified  milk  or  cream  shall 
not  be  subjected  to  heat  unless  specially  directed  by  the  com- 
mission to  meet  emergencies. 

86.  Tests  to  determine  whether  such  milks  and  creams  have 
been  subjected  to  heat  shall  be  applied  at  least  once  each  month. 

Detection  of  heated  milk — Starch's  mctJiod. — Five  cubic  centimeters  of 
milk  are  poured  into  a  test  tube;  a  drop  of  weak  solution  of  hydrogen 
dioxide  (about  0.2  per  cent)  which  contains  about  0.1  per  cent  sulphuric 
acid,  is  added,  and  two  drops  of  a  2  per  cent  solution  of  paraphenylendiamin 
(solution  should  be  renewed  quite  often),  then  the  fluid  is  shaken.  If  the 
milk  or  the  cream  becomes,  at  once,  indigo  blue,  or  the  whey  violet  or  red- 
dish brown,  then  this  has  not  been  heated  or,  at  all  events,  it  has  not 
been  heated  higher  than  78°  C.  (172.5°  F.)  ;  if  the  milk  becomes  a  light 
bluish  gray  immediately  or  in  the  course  of  half  a  minute,  then  it  has  been 
heated  to  79°  to  80°  C.  (174.2°  to  176°  F.).  If  the  color  remains  white, 
the  milk  has  been  heat«d  at  least  to  80°  C.  (176°  F.).  In  the  examination 
of  sour  milk  or  sour  buttermilk,  lime  water  must  be  added,  as  the  color 
reaction  is  not  shown  in  acid  solution. 

Arnold's  guaiac  method. — A  little  milk  is  poured  into  a  test  tube  and  a, 
little  tincture  of  guaiac  is  added,  drop  by  drop.  If  the  milk  hds  not  been 
heated  to  80°  C.  (176°  F.)  a  blue  zone  is  formed  between  the  two  fluids: 
heated  milk  gives  no  reaction,  but  remains  white.  The  guaiac  tincture 
should  not  be  used  perfectly  fresh,  but  should  have  stood  a  few  days  and 
its  potency  have  been  determined.  Thereafter  it  can  be  iised  indefinitely. 
These  tests  for  heated  milk  are  only  active  in  the  case  of  milks  which 
have  been  heated  to  176°  F.  or  80°  C.  (Jensen's  Milk  Hygiene,  Pearson's 
translation,  p.  192.) 

Microscopic  test  for  Jieated    {pasteurized)    milk — Frost  and  Ravenel. — 


APPENDIX.  651 

About  15  cc.  of  milk  are  cenfrifuged  for  five  minutes,  or  long  enough  to 
throw  down  the  leucocytes.  The  cream  layer  is  then  completely  removed 
with  absorbent  cotton  and  the  milk  drawn  off  with  a  pipette,  or  a  fine- 
pointed  tube  attached  to  a  Chapman  air  pump.  Only  about  2  mm.  of  milk 
are  left  above  the  sediment  which  is  in  the  bottom  of  the  sedimentation 
tube. 

The  stain,  which  is  an  aqueous  solution  of  safranin  0,  soluble  in  water, 
is  then  added  very  slowly  from  an  opsonizing  pipette.  The  important  thing 
is  to  mix  stain, and  milk  so  slowly  that  clotting  does  not  take  place.  The 
stain  is  added  until  a  deep  opaque  rose  color  is  obtained.  After  standing 
three  minutes,  by  means  of  the  opsonizing  pipette,  which  has  been  washed 
out  in  hot  water,  the  stained  sediment  is  then  transferred  to  slides.  A 
small  drop  is  placed  at  the  end  of  each  of  several  slides  and  spread  by 
means  of  a  glass  spreader,  as  in  Wright's  method  for  opsonic  index  de- 
terminations. 

In  an  unheated  milk  the  polymorphonuclear  leucocytes  have  their  pro- 
toplasm slightly  tinged  or  are  unstained. 

In  heated  milk  the  polymorphonuclear  leucocytes  have  their  nuclei 
stained.  In  milk  heated  to  63°  C.  or  above,  practically  all  of  the  leucocytes 
have  their  nuclei  definitely  stained.  When  milk  is  heated  at  a  lower  tem- 
perature the  nuclei  are  not  all  stained  above  60°  C.  Tlie  majority,  how- 
ever, are  stained. 

87.  Specific  Gravity. — The  specific  gravity  of  certified  milk 
shall  range  from  1.029  to  1.034. 

88.  The  specific  gravity  shall  be  determined  at  least  once  each 
month. 

The  Quevenne  lactodensimeter  is  recommended  for  the  determination  of 
the  specific  gravity.  It  is  made  like  an  ordinary  aerometer  and  divided 
into  degrees  which  correspond  to  a  specific  gravity  from  1.014  to  1.040,  or 
only  from  1.022  to  1.038,  since,  by  the  latter  division,  a  greater  space  is 
gained  between  the  different  degrees  without  unduly  lengthening  the  in- 
strument. From  such  a  lactodensimeter  one  can  easily  read  oflf  four  deci- 
mal places. 

Tlie  milk  the  specific  gravity  of  wliich  is  to  be  determined  is  well  shaken 
and  poured  into  a  high  glass  cylinder  of  suitable  diameter;  the  aerometer 
is  dropped  in  slowly,  in  order  to  prevent  its  bobbing  up  and  down.  (Tlie 
bulb  should  be  free  from  adhering  air  bubbles.)  The  figures  on  the  stem 
are  the  second  and  third  decimals  of  the  numbers  of  the  specific  gravity,  so 
that  34  is  to  be  read  1.034.  For  this  examination,  the  temperature  of  the 
milk  must  be  15°  C.  (60°  F.)  ;  if  it  is  not,  the  specific  gravity  of  the  milk 
at  15°  C.  must  be  calculated  from  the  specific  gravity  found  and  from  the 
temperature,  for  in  milk  inspection  and  analysis  this  is  the  standard. 


652  THE   DISEASES   OF    CHILDREN. 

Methods  and  Regulations  for  the  Medical  Examination  of  Em- 
ployees, their  Health  and  Personal  Hygiene. 

89.  A  medical  officer,  known  as  the  attending  dairy  physician, 
shall  he  selected  by  the  commission  who  should  reside  near  the 
dairy  producing  certified  milk.  He  shall  be  a  physician  in  good 
standing  and  authorized  by  law  to  practice  medicine;  he  shall 
be  responsible  to  the  commission  and  subject  to  its  direction. 
In  case  more  than  one  dairy  is  under  the  control  of  the  com- 
mission and  they  are  in  different  localities,  a  separate  physician 
should  be  designated  for  employment  for  the  supervision  of 
each  dairy. 

90.  Before  any  person  shall  come  on  the  premises  to  live  and 
remain  as  an  employee,  such  person,  before  being  engaged  in 
milking  or  the  handling  of  milk,  shall  be  subjected  to  a  com- 
plete physical  examination  by  the  attending  physician.  No  per- 
son shall  be  employed  who  has  not  been  vaccinated  recently  or 
who  upon  examination  is  found  to  have  a  sore  throat,  or  to  be 
suffering  from  any  form  of  tuberculosis,  venereal  disease,  con- 
junctivitis, diarrhea,  dysentery,  or  who  has  recently  had  typhoid 
fever  or  is  proved  to  be  a  typhoid  carrier,  or  who  has  any  in- 
flammatory disease  of  the  respiratory  tract,  or  any  suppurative 
process  or  infectious  skin  eruption,  or  any  disease  of  an  infec- 
tious or  contagious  nature,  or  who  has  recently  been  associated 
with  children  sick  with  contagious  disease. 

91.  In  addition  to  ordinary  habits  of  personal  cleanliness  all 
milkers  shall  have  well-trimmed  hair,  wear  close-fitting  caps, 
and  have  clean-shaven  faces. 

92.  When  the  milkers  live  upon  the  premises  their  dormitories 
shall  be  constructed  and  operated  according  to  plans  approved 
by  the  commission.  A  separate  bed  shall  be  provided  for  each 
milker  and  each  bed  shall  be  kept  supplied  with  clean  bedclothes. 
Proper  bathing  facilities  shall  be  provided  for  all  employees  on 
the  dairy  premises,  preferably  a  shower  bath,  and  frequent  bath- 
ing shall  be  enjoined. 

93.  In  case  the  employees  live  on  the  dairy  premises  a  suitable 
building  shall  be  provided  to  be  used  for  the  isolation  and  quar- 
antine of  persons  under  suspicion  of  having  a  contagious  disease. 

The  following  plan  of  construction  is  recommended: 


APPENDIX.  653 

The  quarantine  building  and  hospital  should  be  one  story  high  and  con- 
tain at  least  two  rooms,  each  with  a  capacity  of  about  6,000  cubic  feet 
and  contain  not  more  than  three  beds  each,  the  rooms  to  be  separated  by 
a  closed  partition.  The  doors  opening  into  the  rooms  should  be  on  op- 
posite sides  of  the  building  and  provided  with  locks.  The  windows  should 
be  barred  and  the  sash  should  be  at  least  5  feet  from  the  ground  and  con- 
structed for  proper  ventilation.  The  walls  should  be  of  a  material  which 
will  allow  proper  disinfection.  The  floor  should  be  of  painted  or  washable 
wood,  preferably  of  concrete,  and  so  constructed  that  tlie  floor  may  be 
flushed  and  properly  disinfected.  Proper  heating,  lighting,  and  ventilating 
facilities   should  be   provided. 

94.  In  the  event  of  any  illness  of  a  suspicious  nature  the  at- 
tending physician  shall  immediately  quarantine  the  suspect, 
notify  the  health  authorities  and  the  secretary  of  the  commis- 
sion, and  examine  each  member  of  the  dairy  force,  and  in  every 
inflammatory  affection  of  the  nose  or  throat  occurring  among  the 
employees  of  the  dairy,  in  addition  to  carrying  out  the  above- 
mentioned  program,  the  attending  physician  shall  take  a  culture 
and  have  it  examined  at  once  by  a  competent  bacteriologist  ap- 
proved by  the  commission.  Pending  such  examination,  the  af- 
fected employee  or  employees  shall  be  quarantined. 

95.  It  shall  be  the  duty  of  the  secretary,  on  receiving  notice 
of  any  suspicious  or  contagious  disease  at  the  dairy,  at  once  to 
notify  the  committee  having  in  charge  the  medical  supervision 
of  employees  of  the  dairy  farm  upon  which  such  disease  has 
developed.  On  receipt  of  the  notice  this  committee  shall  as- 
sume charge  of  the  matter,  and  shall  have  power  to  act  for  the 
commission  as  its  judgment  dictates.  As  soon  as  possible  there- 
after, the  committee  shall  notify  the  commission,  through  its 
secretary,  that  a  special  meeting  may  be  called  for  ultimate  con- 
sideration and  action. 

96.  When  a  case  of  contagious  disease  is  found  among  the 
emploj^ees  of  a  dairy  producing  certified  milk  under  the  control 
of  a  medical  milk  commission,  such  employee  shall  be  at  once 
quarantined  and  as  soon  as  possible  removed  from  the  plant, 
and  the  premises  fumigated. 

When  a  case  of  contagion  is  found  on  a  certified  dairy  it  is  advised  that 
a  printed  notice  of  the  facts  sliall  be  sent  to  every  householder  using  the 
milk,  giving  in  detail  the  precautions  taken  by  the  dairyman  under  the 


654  THE  DISEASES  OF   CHILDREN. 

direction  of  the  commission,  and  it  is  further  advised  that  all  milk  pro- 
duced at  such  dairy  shall  be  heated  at  145°  F.  for  40  minutes,  or  155"  F. 
for  30  minutes,  or  167°  F.  for  20  minutes,  and  immediately  cooled  to  50° 
F.  These  facts  should  also  be  part  of  the  notice,  and  such  heating  of  the 
milk  should  be  continued  during  the  accepted  period  of  incubation  for 
such  contagious  disease. 

The  following  method  of  fumigation  is  recommended: 

After  all  windows  and  doors  are  closed  and  the  cracks  sealed  by  strips  of 
paper  applied  with  flour  paste,  and  the  various  articles  in  the  room  so 
hung  or  placed  as  to  be  exposed  on  all  sides,  preparations  should  be  made 
to  generate  formaldehyde  gas  by  the  use  of  20  ounces  of  formaldehyde  and 
10  ounces  of  permanganate  of  potash  for  every  1,000  cubic  feet  of  space  to 
be  disinfected. 

For  mixing  the  formaldehyde  and  potassium  permanganate  a  large  gal- 
van  ized-iron  pail  or  cylinder  holding  at  least  20  quarts  and  having  a  flared 
top  should  be  used  for  mixing  therein  20  ounces  of  formaldehyde  and  10 
ounces  of  permanganate.  A  cylinder  at  least  5  feet  high  is  suggested. 
The  containers  sliould  be  placed  about  in  the  rooms  and  the  necessary 
quantity  of  permanganate  weighed  and  placed  in  them.  The  formaldehyde 
solution  for  each  pail  should  tlien  be  measured  into  a  wide-mouthed  cup 
and  placed  by  the  pail  in  which  it  is  to  be  used. 

Although  the  reaction  takes  place  quickly,  by  making  preparations  as  ad- 
vised all  of  the  pails  can  be  "set  off"  promptly  by  one  person,  since  there  is 
nothing  to  do  but  pour  the  formaldehyde  solution  over  the  permanganate. 
The  rooms  should  be  kept  closed  for  four  hours.  As  there  is  a  slight  danger 
of  fire,  the  reaction  should  be  watched  through  a  window  or  the  pails  placed 
on  a  noninflammable  surface. 

97.  Following  a  weekly  medical  inspection  of  the  employees, 
a  monthly  report  shall  be  submitted  to  the  secretary  of  the  med- 
ical milk  commission,  on  the  same  recurring  date  by  the  exam- 
ining visiting  physician. 

The  following  schedule,  tilled  out  in  writing  and  signed  by 
himself,  is  recommended  as  a  suitable  form  for  the  attending 
physician's  report: 

This  is  to  certify  that,  on  the  dates  below  indicated,  official  visits  were 
made  to  the  dairy,  owned  and  conducted  by of  (in- 
dicating town  and  State),  where  careful  inspections  of  the  dairy  employees 
were  made. 

(a)   Number  and  dates  of  visits  since  last  report. . 

(h)   Number  of  men  employed  on  the  plant.  . 

(c)  Has  a  recent  epidemic  of  contagion  occurred  near  the  dairy,  and 
what  was  its  nature  and  extent  . 


APPENDIX.  655 

(d)  Have  any  cases  of  contagious  or  infectious  disease  occurred  among 
the  men  since  the  last  report?  

(e)  Disposition  of  such  cases.  — . 


(/)   What  individual  sickness  has  occurred  among  the  men  since  the  last 

report? . 

(g)   Disposition  of  such  cases.  . 


(h)   Number  of  employees  now  quarantined  for  sickness. 


(i)    Describe  the  personal  hygiene  of  the  men  employed  for  milking  when 
prepared  for  and  during  the  process  of  milking.  . 


(j)    What  facilities  are  provided  for  sickness  in  employees? 


(fc)    General  hygienic  condition  of  the  dormitories  or  houses  pi  the  em- 
ployees.   . 

(I)    Suggestions  for  improvement.  . 


(m)    What  is  the  hygienic  condition  of  the  employees  and  their  surround- 
ings?   . 

(n)    How  many  employees  were  examined  at  each  of  the  foregoing  visits? 


(o)   Remarks. 


Attending  Physician. 
Date, . 


INDEX. 


INDEX. 


Abdomeii,  palpation  of,  70 
Abscess,  alveolar,  241 

symptoms,  241 

treatment,  241 
peritonsillar,  164 

etiology,  164 

symptoms,  164 

treatment,  165 

retropharyngeal,  161 

symptoms,  161 

treatment,  165 
Abt,  Isaac  A.,  316 
Acetone,  odor  in  cyclic  vomiting,  256 
in  urine,  257,  327 

tests  for,  257,  258 
Acid,  boracic,  in  care  of  nipples,  88 
Adenoids,    165 

etiology,  165 

pathology,  165 

symptoms,  166 

treatment,  167 
and  chronic  rhinitis,  153 
and  tubo-tympanic  catarrh,  175 
Adenitis,  470 
acute,  470 

definition,  470 

etiology,  470 

pathology,  470 

prognosis,  470 

symptoms,  470 

treatment,  471 
chronic,  471 

diagnosis,  472 

symptoms,  472 

treatment,  472 
and  vaccination,  394 
in  scarlatina,  383 
Addison's  disease,  472 

diagnosis,  472 

pathology,  472 

prognosis,  472 

sjonptoms,  472 

treatment,  472 
Adrenal  glands,  tuberculosis  of,  472 
Adrenalin  solution,   153 
Agriculture,    Department    of.    Score 
cards,  122 


659 


Agriculture,  Dept.  of — contd. 

condensed  milk  anavlsis,  132 
Ague,  346 
Albumin  water,  141 
Albuminuria,  477 
cyclic,  478 
functional,  478 
intermittent,  478 
causes,  478 
diagnosis,  478 
etiology,  478 
pathology,  478 
prognosis,  478 
symptoms,  478 
treatment,  479 
Alcoholic  beverages  and  breast  milk, 
97 
stimulation  in  children,  76 
Allen,  118 

Alveolar  abscess,  241 
Amaurotic   family   idiocy,  552 
Amygdalitis,  acute  lacunar,  159 
Anatomy  of  infants,  17 
Anemia,  455 
in  rachitis,  508 
in  rheumatism,  324 
infantum,  456,  464 
definition,  456 
diagnosis,  457 
etiologj',  456 
pathology,  456 
prognosis,  457 
symptoms,  456 
treatment,  457 
pernicious,  450 
j)rimary,  455 
secondary,  455 
symptomatic,  455 
Angina  in  scarlatina,  382 
Ani,    sphincter,    dilation    of,    in    as- 
phyxia, 28 
Animal  broths,  141 
Animal  Industry,  Bureau  of,  122 
Ankylostoma  duodenale,  291,  456 
description,  201 
diagnosis,  292 
prognosis,  292 
symptoms,  2t>l 


660 


INDEX. 


Ankjiostoma    duodenale — contd. 

sj'nonyms,  291 

treatment,  292 
Anodynes,  77 
Anopheles,  348 

Antibodies  in  antitoxin  therapy,  421 
Antimony  and  ipecac  tablets,  205 
Antipyretics,  medicinal,  76 

bath  as,  77 
Antitoxin,  diphtheria,  412 

complications  following,  421 

in     diphtheretic     conjunctivitis, 
193 
Anus,  imperforate,  in  new-born,  30 
Aortic  regurgitation,  444 

pathologj',  444 

physical  signs,  444 

symptoms,  444 
stenosis,  445 

pathology,  445 

physical  signs,  445 

prognosis,  446 

symptoms,  rr45 
Aphthae,  Bednar's,  234,  239 

etiology,  234 

pathology,  234 

symptoms,  234 
Aphthous  stomatitis,  235 
Appendicitis,  296 

blood  count  in,  299 

definition,  296 

diagnosis,  300 

etiolog\',  296 

pathology,  296 

prognosis,  301 

symptoms,  298 

treatment,  301 

in  typhoid  fever,  316 
catarrhal,    296 

symptoms,  298 
gangrenous,  297 

symptoms,  299 
and  pneumonia,  222 
sc-lerotic,  297 

symptoms,  300 
ulcerative,  297 

symptoms,   299 
Appendix,  598 
Aprosexia,  154,  166 
Argyrol  solution,  153 

in  eyes  of  new-born,  30 
Arneill,  24 
Arnold  bottle,  124 
Arrowroot  gi'uel.  1^*2 
Arteries,  superior  vesicle,  17 
Arthritis,  324 

diagnosis  from  rheumatism,  324 


Arthritis — con  td. 

septic  or  tubercular,  324 
in  scarlatina,  383 
Artificial  foods,  148 
Ascaris  lumbricoides,  289 
description,  289 
diagnosis,  290 
eggs  of,  290 
symptoms,  290 
treatment,  290 
Ascites  in  mitral  stenosis,  443 
Asphyxia,    forms   of,   25 
prognosis,  26 
symptoms,  26 
treatment,  26 
Aspirin  in  tonsillitis.  158 
Aspiration  in  pleurisy,  227 

empyemia,  230 
Asthma,  202 

etiology,  202 
physical  signs,  202 
symptoms,  202 
treatment,    203 
Astigmatism,  mixed,  187 
Ataxia,  hereditary,  550 
diagnosis,  551 
etiologj',  550 
pathology,  550 
prognosis,  551 
symptoms,    551 
treatment,  551 
Atelectasis,  44.  203 
etiology,  44.  203 
pathology,  44,  203 
symptoms,  44,  204 
treatment,  44,  204 
following  asphyxia.  26 
Anthrepsia,  501 
diagnosis.  502 
etiology,  501 
pathology,  501 
prognosis,  503 
symptoms,  502 
treatment,  503 
Atrophy,   Infantile.  501 
Auditory  canal,  diseases  of  external, 

17S 
Ausculation.  70 
position  for,  71 

B 

Babcock.  129,  434,  436,  446 

milk  tester.  129 
Babies,  care  of,  in  hot  weather,  619 

Milk   Fund   Association  of  Louis- 
ville, Kv.,  128,  619 

outfit,  32 
Baby,  preparation  for,  32 


INDEX. 


661 


Babiiiski's  reflex,  G5.  335,  515,  559 
IJa'illus  coli  communis,  246,  212 

cyanogene,  105 

hay,  237 

Klebs-Locfflcr,    116,   212 

lactis  aerogcnes,  246 

Pfeiirer,   407 

Shiga,  246 

subtilis,  246 

tubercle  and  milk,  116 

typhoid  and  milk,  116 

viscosus,  105 

Week's,  189 
Bacteria  in  milk,  105,  117,  246 

•lactic  acid,  in  milk,  105 

of  stomach  and  intestines,  246 
Bacterial  count,  method  of,  in  milk, 

642 
Baej-er's  test  for  acetone,  258 
Balanitis,  494 
etiology,  494 
symptoms,  494 
treatment,  495 
Ballantyne,  24 

Bauer's  milk  modification,  598 
Barley  giuel,  139 
Barlow's  disease,  504 
Barnes,  H.  A.,  158 
Barnhill,  178,  183 
Basket,  contents  of  baby's,  32 
Bassinet,  30 
Bastianelli,  347,  354 
Bath,  77 

bran,  79 

brine,  80 

mustard,  79 

Nauheim,  80 

soda,  79 

temperature,  31 

for  temperature,  77 

thermometer,  77 

tub.  78 
Bathing  of  new-born.   31 
Bednar's   aphth.T,   234,   239 
Bed-wetting,  491 
Beef  juice,   141 

scraped,  143 
Bein.  353 
Bell's  palsy.  534 
Bengue  analgesique   balm,   325 
Benzoin  in  inhalations.  75 
Bermuda  arrowroot,   142 
Bevan's    operation    for    undescended 

testicle,  499 
Bir-eps  jerk,  514 
Biedert,  136 

cream  mixture,  135 


Bignami,  347,  353 
Bland  Nuhn  gland,  240 
Bleeder,  37,  467 
Blepharitis,  187,  189 
etiology,   187 
symptoms,   1 88 
treatment,   188 
Blisters,  77 
Blood,  451 

changes,  general  consideration  of, 

454 
corpuscles,  red,  453 

white,  453 
count  in  appendicitis,  299 
diseases,  451 
letting  in  nephritis,  486 
method  of  examination,  451 
picture  in  malaria,  353 
Bloom,  I.  X.,  588 

Bone-marrow,  in  pernicious  anemia, 
456 
in  leukemia,  463 
Bordet,  3yj 
Bosses  on  bones,  509 
Bothriocephalus  latus,  459 
Bottles,   124 
annealing,  124 
Arnold,  124 
care  of  nursing,   123 
hygeia  nursing,  124,  147 
pasteurizing,   116 
Thermos,   and  milk,   114 
Whitehall   Tatum,    124 
Bouzian,   353 
Bowles'  stethoscope,  70 
Bradycardia,  448 
etiology,  448 
symptoms,  448 
Brain,  abscess  of,  572 
diagnosis,  572 
etiology,  572 
pathology,  572 
prognosis,  572 
symptoms,  572 
treatment,  573 
at  birth,  24 
diseases  of,  555 
tumors,  570 
diagnosis,  571 
etiologj',  570 

localization  symptoms,  571 
])atliology,  570 
prognosis,  571 
symptoms,  570 
tTeatment,  571 
Bran  bath,  79 


662 


INDEX. 


Branchial  fistula,  242 

treatment,  242 
Breast-feeding,  contra-indications  to, 
88 
milk,  amount  at  feeding,  92 
composition,  91 
examination,  91 
supervision,  94 
Brideau.  363 
Brill,  315 
Brine  bath,  80 
Bright's  disease,  acute,  483 
Broucliial  glands,  at  birth,  19 
tubes,  200 

foreign  bodies  in,  200 
diagnosis,  200 
symptoms,  200 
treatment,  201 
Broncliitis,  acute  catarrhal,  204 
diagnosis,  206 
from  broncho-pneumonia,  206, 

215 
etiology,  204 
pathology,  205 
physical  signs,  206 
prognosis,  206 
symptoms,  205 
treatment,    207 
capillary,  212 
chronic  catarrlial,  209 
diagnosis,  210 
pathology,  209 
physical  signs,  209 
prognosis,  210 
symptoms,  209 
treatment,  210 
and  heart  disease,  432 
in  typhoid  fever,  313 
Broncho-pneumonia,   212 
and  heart  disease,  342 
in   typhoid   fever,  313 
Broths,   animal,   141 
Brown,  339 
Bruce,  E.  T.,  201 
Bruit  de  diable,  459 
Buccal  eruption  of  measles,  07,  309 
Budin,  Pierre,  137 
Bureau  of  Animal  Industry,  122 
Burns.  Wm.  Britt,  346 
Busey  &  Kober,    112 
Butterick's  fashions,  33 
Buttermilk,  142 
Buttocks,  31 
Byrd-Dew  Treatment  of  asphyxia,  27 

C 
Cabot,  299 


Calcium  paracasein,  119 
Calculus,  as  caiise  of  pyelitis,  479 

Renal,  481 
Calmette  test  in  tuberculosis,  339 
Calomel  vapor  inhalations,  76 
Calorie,  138 

Camphor  as  a  stimulant,  77 
Cancarem  oris,  236 
Caput  succedaneum,  17,  36 
Carbohj'drates,  120 
Cascara  excreted  in  milk,  90 
Casein,  119 

action  of  acid  on,  119 

calcium,  119 

calculating      amounts      in      herd 

milk,  145 
and  citrate  of  soda,  145 
Cassellberry,  426 
Catarrh,  acute  gastric,  248 
nasal,  152 

of  conjunctiva,  vernal,  192 
Catarrhal  pneumonia,  212 
Census  report  on  milk,  115 
Cephalhematoma,  differentiation 

from  hernia  cerebri,  436 
treatment  of,  37 
Cereal  gruels,  percentage,  144 
Cerebral  hemorrhage,  49,  573 

localization,  571 
Cerebral  palsies,  567 
Cerebrospinal  fluid  in  spotted  fever, 

558 
Cerebrospinal  sclerosis,  549 
Cereo,  138 
Certified  milk,  100,  104 

methods  and  standards  for  produc- 
tion and  distribution  of,  632 
Cestodes,  293 

Chautard's  test  for  acetone,  258 
Chapin,  85,  131,  476,  625 
cream  dipper,  130 
urinal.  476 
Chest,  regions  of,  62,  63 
Chevne  Stokes  respiration,  334,  563, 

571 
Chicken-pox,  389 
Chloral.  77 
Chlorosis,  458 

diagnosis.  459 
etiology,  458 
pathologj",    458 
prognosis.  459 
symptoms,  459 
treatment,  459 
Cholera  infantum,  266 
definition,  266 


INDEX. 


663 


Cholera   infantum — contd. 
diagnosis,  267 
etiology,  266 
pathology,  266 
prognosis,  267 
symptoms,  267 
treatment,  268 
Chorea,  520 
electric,  525 
habit,  524 

diagnosis,  524 
symptoms,  524 
treatment,  524 
hereditary,  523 
etiology,  523 
prognosis,  524 
symptoms,  523 
treatment,   524 
minor,  520 

definition,  520 
etiology,  520 
pathology,  521 
symptoms,  521 
treatment,  522 
in  typlioid  fever.  312 
posthemiplegic,  522 
and  rheumatism,   323 
Sach's  sign  of,  65 
severe,  521 

Sydenham's,   520  • 

varieties,  520 
Christian.  Frank  L.,  554 
Churchill-Loper,  402,  498 
Circulation  at  birth,  17 

fetal,  19 
Cireulatorv  system,  diseases  of,  430 
Circumcision,^  32,  493,  495 
Citrate  of  soda  in  breaking  up  curds, 

145 
Clavicle  at  birth,  18 
Climate  in  bronchitis,  210 
Clubbing  of  fingers  in  mitral  steno- 
sis, 443 
Coccus  of  trachoma,  190 
Cod-liver  oil  in  condensed  milk  feed- 
ing,  132 
Coit,  Henry  L.,  100 
Colds,  165 
Colic,  259 

diagnosis,  261 
symptoms,  260 

treatment,  during  attack,  261 
preventive,  261 
in  renal  calculus,  482 
Colin,  L.,  358 
Colles'  law,  362 
Colon,  282 


Colon — contd. 
dilation  of,  282 
diagnosis,  286 
etiology,  282 
pathology,  283 
prognosis,  286 
symptoms,  283 
synonyms,  282 
treatment,  286 
giant,  282 
irrigation  of,  84 
mega,  282 

bacillus  of,  cause  of  pyelitis,  479 
Colostrum,  87,  95 
analysis  of,  95 
disagreement,  96 
Combined   feeding,  99 
Comby,  472 
Comforter.  60 

Commission,  Medical  Milk,  632 
Compensation,  in  heart  lesions,  441 

rupture  of,  441 
Condensed  milk,  131,  132 
Condylomata,  364 
Congenital  heart  lesions,  431,  432 
Conjunctiva,  vernal  catarrh  of,  192 
Conjunctivitis,  189 
etiology,   189 
sj'mptoms,  190 
treatment,  190 
diphtheritic,  193 
etiologj',   193 
pathology,  193 
symptoms,  193 
treatment,  193 
gi-anular,  192 

treatment,  192 
in  measles,  365 
phlvctenular,   193 
etiology,  193 
pathology',  194 
symptoms,   194 
treatment,  194 
Connor's   tables,   milk    modification, 

595 
Constipation,  278 
etiology,  278 
prognosis,   280 
symptoms,  279 
treatment,  280 
medicinal,    281 
Contagious  diseases.  368 
incubation,  417,  426 
quarantine,  417,  426 
Convulsions,  518 
etiologj',  518 
prognosis,  519 


664 


INDEX. 


Convulsions — conld. 
symptoms,   518 
treatment,  519 
Convulsive  tie,   524 
Cor  bovinum,  444 
Cord,  umbilical,  ligature,  29 
spinal,  diseases  of,  536 

syphilis  of,  548 
umbilical   dressing,   28 
family  disease  of,  550 
Corlett,  390 
Cornea,  diseases  of,  198 
opacity  of,  191 
pannus  of,  191 
ulcer  of,   195 
Cornet,  331 

Corona  glandis  at  birth,  23 
Corpuscles,  red  blood,  453 
Corrigan  pulse,  444 
Corsets  and  depressed  nipples,  87 
Cotton,  A.   C,   145 
Counter-irritants,  77 
in  bronchitis,  207 
Councilman,   395 
Coutts,  J.  A.,  216 
Cow-pox,  391 

Cows,    unsuspected    but     dangerous 
tubercular,   110 
of  different  breeds,  milk  from,  118 
milk,   100 

milk  and  mother's  milk,  compara- 
tive analysis,  100 
Cowlings,  rule  for  dosage,  74 
Cragin  method  of  milk  modification, 

606 
Craniotabes,  364,  508 
Cream  dipper,   130 

and   whey   feeding,    134 
mixture,  Biedert,   135 
Credo's  treatment  of  ejes,  30 
Cremaster  reflex,  514 
Cretinism,  473 

definition,  473 
diagnosis,  473 
etiology,  473 
pathology,  473 
prognosis,  474 
symptoms,    473 
treatment,  474 
Crocker,  592 
Crofton,  477,  478,  479 
Croup,  168 

diagnosis,  from  diphtheria,  169, 

418 
inhalation  in,  75 
kettle,    170 
spasmodic,  168 


Cry,  child's,  64,  65 

Cryptorchid,  24,  499 

Cups,   dry,   in   nephritis,   486 

Curds  in  infant  stools,  144 

Cushing,  543 

Cutaneous     diagnosis     tuberculosis, 

340 
Cyclic  vomiting.  256 

diagnosis,  257 

etiology,  256 

prognosis,   258 

symptoms,   256 

treatment.  258 
Cvst,  branchial,  242 
Cystitis,  498 

prognosis,  498 

symptoms,  498 

treatment,  499 

D 

Da  Costa,  506 

Dactylitis  in  lues,  363 

Dairies,  inspection  of,  122 

Deming  milk  modifier,  604 

Dermographism,  596 

Dentition,  57 

Dermatitis    herpetiformis,   diagnosis 

from  pemphigus,  587 
Development  in  growth,  53 
Dextrinizing  agents.  138 
Diabetes  mellitus,  326 
complications,  328 
definition,  326 
diagnosis,  328 
etiology,  327 
frequencv,  327 
patliology,  327 
prognosis,  328 
symptoms,  327 
treatment,  328 
Diagnostic  methods   in  nervous  dis- 
eases, 513 
Diarrhea,  from  milk,  115 

inflammatory,  269 
Diazo  reaction,  314 
Diet  after  first  year,  146 

from   twelfth   to  fifteenth   month, 

147 
from      fifteenth      to      eighteenth 

month,  147 
of  nursing  mother,   89 
to  be  avoided  after  first  year.  147 
Digestive  system,  diseases  of,  233 
Digitalis  in  heart  lesions,  433 
Diluents  in  milk  formuUe.  138 
Diphtheria,  410 

diagnosis,    160,   417 


INDEX. 


665 


Diphtheria — contd. 

bacteriological,   416 
from  croup,   169 
from  tonsillitis,   160,  418 
antitoxin,   412 
bacteriology,  410 
casts,  416 
chart  of,  414 
complications,  417 
complications  following  antitoxin, 

421 
and  heart  disease,  4.31 
quarantine   in,  427 
cause  of  nephritis  in,  483 
epidemics  and  milK,  114 
etiology,  410 
membrane  in,  411 
pathology,    413 
quarantine  in,  427 
symptoms,  414 
treatment,  419 
curative,   420 
general,  421 
local,  422 
medicinal,  421 
prophylactic,  419 
prognosis,  4I9 
Dipper,  Chapin  cream,   130 
Diseases,  of  blood,  451 

circulatory,  430 
.  contagious,  368 
digestive   system,  233 
ear,   172 

foot  and  mouth,  116 
general,  307 

genito-urinary  system,  476 
hookworm,  291 
larynx,  152 
lymphatic  gland,  469 
nervous  system,  513 

diagnostic  methods  in,  513 
functional,  518 
nose,   152 
Pott's,  545 

X-ray  of,  546 
spinal  cord,  536 
stomach  and  intestines,  245 
throat,  152 
wasting,  501 
Disinfection,    429 
Disorders  of  sleep,  531 
Distichiastis,  191 
Dobell's  solution,  154,  161,  176 
Dochez,  536 
Draper,  536 

Dropsy  in  mitral  regurgitation,  434 
Drugs  excreted  by  breast,  96 


Dubini,  525 
Duchek,  353 
Dunlop,  216 
Dunn,  561 
Dysentery,  269 
Dyspnea,  and  heart  disease,  432 
Dyspepsia,  acute,  248 
Dystrophy,      progressive     muscular, 
552 

E 
Eager,  115 
Ear,  diseases  of,  172 
infant's,  18 
middle,  174 

examination,  68 
inflammations  of,  175 
specula,  68 
Eberth,  308 
Ectropion,  191 
Eclampsia,  infantile,   518 
Eczema,  590 

etiology,  590 
pathology,  590 
prognosis,   592 
symptoms,  590 
treatment,  592 
erythematosum,   591 
papulosum,  591 
pustulosum,  592 
squamosum,  592 
vesiculosum,  591 
Eczematous  coniunctivitis,   193 
Edebohls,  Geo.  M.,  487 
Edwards,  35 
Ehrlich,  367,  464 
Electric     examinations     in    nervous 

diseases,  515 
Emmetropia,   187 
Emphysema,  210 

compensation  in,  211 
etiology,  211 
pathology,   211 
symptoms,   211 
treatment,  211 
and   pertussis,  395 
Empyema,  228 

diagnosis,  229 
etiology,  228 
pathology,   228 
physical    signs,    229 
prognosis,  230 
symptoms,    228 
treatment,  230 
after,  231 
Encephalitis,  acute,  563 
etiology,  563 


666 


INDEX. 


Eiiceplialitis — contd. 
pathology,  563 
prognosis,  564 
symptoms,   563 
treatment,  564 
Endocarditis,  438 
etiology,  438 
pathology,   438 
physical  signs,  439 
prognosis,  439 
symptoms,  439 
treatment,  439 
chronic,  441 

pathology,  441 
fetal,  432 
malignant,  440 
etiology,  440 
pathology,  440 
prognosis,  441 
symptoms,  440 
treatment,  441 
Enemata,  74 

nutrient,  74 
Enteric  fever,  307 

infection,  269 
Enteritis,  269 

from  milk,  115 
Enterocolitis,  acute,  269 

course  and  duration,  272 
diet,  264 
etiology,  269 
-  hygiene,    266 
pathology,  269 
prognosis,  272 
symptoms,   271 
treatment,  273 
general,  273' 
hygienic,  275 
medicinal,  274 
preventive,  272 
chronic,  275 
diagnosis,  276 
pathology,    276 
prognosis,  277 
symptoms,  276 
treatment,  277 
dietetic,  277 
hygienic,   277 
medicinal,  278 
Enterocolysis,  76 
Entropion,  191 
Enuresis,  491 

definition,  491 
etiology,  491 
prognosis,  491 
symptoms,  491 
treatment,  491 


Eosinophiles,  454 

Eosinophilia,  455 

Epidemics  due  to  milk,  112,  113,  114 

Epilepsy,  527 

diagnosis,  529 
etiology,   528 
pathology,   528 
symptoms,  528 
treatment,  530 
Epistaxis,  154,  155 
etiology,  155 
prognosis,  530 
symptoms,  155 
treatment,  156 
in  atrophic  rhinitis,  154 
Epithelial   desquamation   of   tongue, 

233 
Epstein,  82,  83 
Erb's  paralysis,  535 

type  of  muscular  dystrophy,  552 
Erysipelas     complicating     varicella, 

383 
Erythema      multiforme,      diagnosis 
from  pemphigus,  587 
nodosum,  323 
in  rheumatism,  324 
Esophagitis,  242 
symptoms,  242 
treatment,  243 
Esophagus,    five   cent   piece    in,    201 
Eustachian  tubes  at  birth,  18 

valve,  19 
Ewing,  356 
Examination,  methods  of,  62 

physical,  in  pediatrics.  62 
Exanthemata,     cause     of    nephritis, 
485 
acute,  368 
Extremities,    upper    and    lower    at 

birth.   16 
Extubation,  426 

Eye,   Crede's   treatment   of   the,   29, 
195 
diseases  of  tlie,  187 
pink,  189 
Eyelids,  method  of  everting,  187 
Eye-strain,  187 

F 

Facial  palsy,  534 
Family  disease  of  cord,  550 
Fat,  Babcock's  test  for,  in  milk,  129 
disease   of,   in   breast   feeding,   97, 

98 
disagreement  of,  in  breast  milk,  97 
increase  of,  in  breast  feeding,  97, 
98 


INDEX. 


667 


Fat — contd. 

in  milk,  120,  121) 
too  much,  in  milk  feeding,  144 
Favus,  580 
Feces,  247 
Feeding,  artificial,  99 

breast,  supervision  of,  94 
combined,  99 
difficult  cases,  145 
infant,    87 
by  rectum,   150 

position  for,   in  intubation   cases, 
425 
Fetal,  circulation,  19 

heart,  condition  of,  in  heterotaxia, 
9 
Fever,  blister,  593 

chart  in,  diphtheria,  414 
lobar  pneumonia,  219 
malarial  hemoglobinuria,  358 
measles,  370 
German,  377 
and   pneumonia,   371 
pemphigus,  589 
typhoid  fever,  310,  312 
tuberculosis,  333 
intermittent,  346 
lung,  218 
rheumatic,  322 
scarlet,  and  milk,  112 
typhoid,  307 
and  milk.  113 
Finnev,  J.  M.,  285 
Fistufa,  of  neck,  242 
symptoms,   242 
treatment,  242 
Fleckern,  368 
Flexner,  561 

Flora,  bacterial,  in  intestines,  247 
Fontanelles,  17 
Food,  artificial,  148 
proprietary,  148 
strength  of,  for  different  months, 

146,   147 
to  be  avoided,  148 
Foot  and  mouth  disease.  110 
Foramen  ovale,  patency  of,  432 
Forceps,  high,  47 

Foreign    bodies    in    broncliial    tubes. 
200 
diagnosis,  200 
svmptoms,   200 
treatment.  200 
matter  in  milk,  104 
Fotzke,  549 
Foulouse,  531 
Fraenkel,  399 


Francisco,  Stephen,  100 

Friedreich's  disease,  550 

Frontal  bone  at  birth,  17 

Fuller,  468 

Functional    disorders    of   the    heart, 

448 
Furunculosis  and  diabetes  mellitus, 
328 
of  external  auditory  canal,  172 
etiology,    172 
pathology,  172 
symptoms,   172 
treatment,    172 

G 

Gaertner's  mother's   milk,   149 
Gangrene  of  cheek,  236 
of  lung,  231 

etiology,  231 

pathology,   231 

physical  signs,  232 

symptoms,  232 

treatment,  232 
Gargles,  75 
Garrod,  521 
Gastralgia,  262 

diagnosis,  262 

symptoms,  262 

treatment.   262 
Gastrectasia,  255 
Gastric  catarrh,  acute,  248 

diagnosis,  249 

etiolog}',  248 

pathology,  248 

prognosis,  249 

symptoms,  248 

treatment,  249 
dilatation,   255 

etiology,  255 

pathologj',  255 

prognosis.  255 

symptoms,  255 

treatment,  255 
disorders,   248 
indigestion,   acute,  248 
Gastritis,  acute.  248,  251 

etiology,  251 

pathology,  251 

prognosis,  251 

symptoms,  251 

treatment,  251 
chronic,  252 

diagnosis,  253 

etiology,   252 

pathology,  252 

prognosis,   252 

treatment,  252 


668 


INDEX. 


Gastro-enterie  infection,  acute,  263 
etiology,   263 
pathology,  263 
prognosis,  264 
symptoms,    264 
treatment,  dietetic,  264 
hygienic,  266 
medicinal,   265 
prophylactic.  264 
Gastro-enteritis,  263 
Gastro-intestinal    hemorrhage,    40 

indigestion,  275 
Gavage,   149 

Gelatin  in  hemorrhage,  41 
Gengou,  399 

Grenitals,  care  of,  in  new-born,  32 
Genito-urinary    system,    disease    of, 

476 
Genu-valgumin  rachitis,  509 
Genu-varum  in  rachitis,  509 
Geographical  tongue,  234 
German  measles,  376 
quarantine  in,  428 
Glands,  bronchial,  at  birth,  19 
lymphatic,  diseases  of,  469 
suprarenal,  at  birth,  21 
thymus,  at  birth,  19,  469 
tuberculosis,  229 
Glioma,  570 
Globus  hystericus,  526 
Golgi,  521 

Gonorrheal  infection  of  mouth,  239 
■  Grand  mal,  528 
Granulated  lids,   190 
Graves'      disease,      diagnosis      from 

tachycardia,  449 
Griffiths,  316' 
Grip,  407 
Groff,  A.,  346 
Growing  pains,  322 
Growth  and  development,   53 
Gruels,  97,   139 
arrowroot,   142 
Keller's    method    of    dextrinizins, 

138 
percentage  cereal,  144 
Guiseppe,  240 
Gummata,  365 

H 
Hair  of  new-l)orn,  35 
Hale's  method  of  milk  modifi"ation, 

610 
Hamilton's  method  of  milk  modifica- 
tion, 601 
Hart,  E.,  119 
Hay,  bacillus,  245 
Hayem,  453 


Head,  at  birth,  17 
moulding  of,  17 
Headache  in  eye-strain.  187 
Heart,  430 

congenital  lesions,  431 
defects,  430 
diagnosis.  432 
disea.ses  of,  430 
etiology,  431 
prognosis,  433 
symptoms,   432 
treatment,  433 
auscultation  of,  72 
fetal,    19 

functional   disorders,  448 
in  heterotaxia,  24 
involvement  in  rheumatism,  431 
Heat,  effect  of,  on  milk,  117 
Heine,  536 

Hemic  murmurs,  457 
Hematuria  in  purpura,  459 
Hemiplegia,  spactic,  567 
Hemoglobin  in  chlorosis,  458 
pernicious  anemia.  456 
pseudo-leukemia,  405 
scale.  Dare's,  452 
Tallquist,  452 
Hemoglobinometer,   Von    Fleischel's, 
452 
Oliver's,  452 
Hemophilia.  37,  467 
diagnosis,  468 
etiology,  467 
pathologj',  468 
prognosis,  468 
symptoms,  468 
treatment,  468 
Hemorrhage : 

cerebral,  49,  565 
etiologA-.   573 
prognosis,  573 
symptoms,  573 
in  cord,   diagnosis  from   myelitis, 

544 
intracranial,  573 
subdural,  573 
of  new-born,  38 
etiology,  39 
location.  39 
j)rognosis,  41 
treatment,  41 
in  typlioid  fever,  312 
umbilical,  37 
Henoch,  41 

purpura,  467 
Hereditary,  ataxia,  550 
spastic  paralysis,  551 


INDEX. 


669 


Hereditary  in  malaria,  353 

and  leukemia,  461 
Hernia,  umbilical,  20,  42 
cerebri,  30 
contents  of,  43 
in  pertussis,  400 
treatment  of,  43 
Herpes,  593 
facialis,  594 
zoster,  594 

definition,  594 

diagnosis,  595 

etiology,  594 

symptoms,    594 

treatment,  595 
in  rheumatism,  324 
Herz's  arm  test  in  rheumatism,  322 
Heterotaxia,  24 
Hess  refrigerator,  631 
Heubner,  136 
High  forceps,  47 
Hirschprung's  disease,  282 
History  card,  64 
Hives,  596 

Hodgkins'  disease,  464,  472 
Holt.  35,  91,  93,  142,  566 
Holt's  milk  set,  91 
Hookworm  disease,  291 
Hordeolum,  188 

etiology,   188 

symptoms,  188 

treatment,   189 
Horse  serum,  468 
Hospital,  sick  children,  216 
Huntington's  chorea,  523 
Hydrocele,  494 

definition,  494 

symptoms,  494 

treatment,  494 
Hydrocephalus,  acute,  564 

etiology,  564 

pathology,   564 

prognosis,  564 

symptoms,  564 

ti-eatment,  565 
chronic,  565 

diagnosis,  567 

etiology,   565 

prognosis,  567 

symptoms,  565 

treatment,  567 
Hydronephrosis,  490 

definition,  490 

etiology,  490 

pathology,  490 

prognosis,  490 

symptoms,  490 


Hydronephrosis — con  td. 

treatment,  490 
Hydrothorax,  438 

menstruation  in,  73 
Hygiea  bottle,  124 
pasteurizer,  116 
Hyperopia,  187 
Hypodermoclysis,  76 
Hysteria,  525 

diagnosis,  526 
etiology,  525 

motor  manifestations,  526 
sensory   manifestations,   525 
symptoms,  525 
treatment,   527 
in  chlorosis,  459 
mental  manifestations,  526 
Hysterical  mania,  527 


Icterus  in  new-born,  44 
etiology,  45 
symptoms,  45 

treatment,  45  * 

Idiocy,  Lorain  type,  474 

Mongolian,  473 
Ileocolitis,  269 
Imperial  granum,  148,  149 
Impetigo,  contagiosa,  585 
diagnosis,  585 
etiology,  585 
pathology,  585 
symptoms,  585 
treatment,  586 
Inanition,  501 

Incubation   and   quarantine   of   con- 
tagious diseases,  426 
Indigestion,  diagnosis  from  appendi- 
citis, 300 
acute  gastric,  248 
Indigo  test,  258 
Infant  feeding,  87 

care  of,  in  hot  weather,  619 
Infantile  paralysis,  536 
Infantilism,    diagnosis   from    cretin- 
ism, 474 
of  Lorain  tj'pe,  474 
Infectious    diseases    cause    of    heart 

lesions,  431 
Influenza,  407 
Inhalation,  75 

calomel  vapor,  76 
Injuries  to  new-born,  47 
Inoculation      treatment      in      vulvo- 
vaginitis, 497 
Inspection  of  child,  64 
Insufflation  in  asphyxia,  27 


670 


INDEX. 


Insular  sclerosis,  549 
Intertrigo,  16,  575 
treatment,  575 
Intestinal  parasites,  287 
Intestines,  245 
bacteria  of,  245 
disease  of,  245 
surgical  condition  of,  296 
tuberculosis  of,  329 
Intubation,  422 
indications,  423 
operation,  424 
position  for  operation,  425 
position  for  feeding  in,  425,  426 
Intussusception,  302 
diagnosis,  304 
etiology,   303 
pathology,  302 
prognosis,  305 
symptoms,  303 
treatment,  305 
palpation  of  rectum  in,  70 
Intussusceptuni,  302 
Intussuscipiens,  302 
Inunction,  86 

lodiform  test  for  acetone,  257 
Irrigation  of  colon,  84 
Iron  persulphate  in  umbilical  hemor- 
rhage, 37 
Itch,  578 


Jackson,  202 
Jacksonian  epilepsy,  529 
Jacobi,  331 
Jelly,  oatmeal,  143 
Jenner,  Edw.,  391 
Juice,  beef.  141 
Junket,  134,   140 
Hansen  tablets,  141 

K 
Kahn,  Lee,  416 
Keating,  35 

Keller's  malt  soup,  138 
Kelly,  301 

Keloid  and  vaccination,  394 
Kentucky's   law   and   certified   milk, 
101 
Agricultural  College,  128 
Keratitis,  phyctenular,  198 
etiology,' 198 
symptoms,  198 
treatment,  198 
interstitital,    199 
pathology,   199 
symptoms,  199 


Kerley,   80,   90;  132,   138,   140,  320, 

628 
Kernig's  sign,  65,  335,  515 

in  cerebrospinal   meningitis,  559 
Kettle,  croup,   170 
Kidneys,  at  birth,  20 
tumors,  488 
diagnosis,  489 
etiology,  489 
prognosis,  489 
symptoms,  489 
treatment,  490 
benign,  488 
decapsulation  of,   487 
sarcoma,  488 
stone  in,  481 
tuberculosis,  330 
Killain,  202 
Kilmer,  T.  W.,  64,  404 
King,  347 
Klebs-Loeffler     bacillus,      116.      175, 

410 
Klimenco,  399 
Knee-jerk,  514 
Kober  and  I?usev,  112 
Koch,  108,  339  ' 
Koplik,  41,  369 
spots,  67,  369 
Kumyss,  142 
Kupfer's  cells  in  malaria,  355 


Laboratory  milk,  128 

Walker  Gordon,  125 
Laborde  treatment  of  asphj'xia,  28 
Lactalbumin,  120 
Lactation  history.  96 
Lactic  acid  bacteria,  105 
Lactoglobulin,  120 
Lactone  tablets,    142 
Ladd's  cereal  decoction,  140 

tables  milk  modification,  607 
La  grippe,  407 

complications,  408 

diagnosis,  409 

etiology.  407 

pathology,  407 

prognosis,  409 

symptoms,    407 

treatment,  409 
and  heart  disease,  431 
Landouzy-Dejerine  type  of  muscular 

dystrophy,  552" 
Landry,  538 
La   Noble's   test  for   acetone,   258 
I^anghan's  cells,  363 
Lanugo,  35  . 


INDEX. 


671 


Larrier,  Nathan,  363 
Laryngitis,  acute  catarrhal,  168 
diagnosis,   169 
etiology,  168 
prognosis,  169 
symptoms,  169 
in  measles,  372 
Laryngismus  stridulus,  169,  510 
I>arvnx  at  birth,  18 

diseases  of,  152,  168 
Laveran,  347 
Leach,  118 
Leeches,  186 
Leishman's  stain,  351 
Lemon  juice  as  styptic,  155 
Leucocytes,  degenerated,  453,  454 

number  of,  454 
Leucocytosis  in  appendicitis,  299 
in  pertussis,  402 
neutrophilic,  455 
Leucopenia,  455 
Leucorrhea  in  chlorosis,  459 
leukemia,  lymphatic,  461 
Levy,  307 

Lieben's  test  for  acetone,  257 
Liebig's  foods,   149 
Lichen  urticatus,  596 
Lips,  disease  of,  233 
Liver,  at  birth,  20 
Lockjaw,  49 
Loeffler's  solution,  158,  161 

stain  typhoid  bacillus,  308 
Lorain  tvpe  idiocy,  474 
Lues,  361 
Lumbar   puncture.   516 

in    cerebrospinal   meningitis,    518, 

561 
in  tubercular  meningitis,  335,  516 
Limibricoides,  ascaris,  289 
l^ungs,  at  birth,  18 
gangrene   of,   23 1 
Lymphatic  glands,  disease  of,  409 
leukemia,  461 
acute  form,  461 
definition,  461 
etiology,  4()1 
myeloid,  461 

diagnosis,  402 
pathology,  462 
prognosis,  462 
symptoms,  462 
treatment,  462 
chronic  form,  462 
diagnosis,  463 
etiology,  462 
pathology,  463 
prognosis,  463 


Lymphatic    glands — contd. 

symptoms,  463 

treatment,  463 
Lymphatism,  501 
Lymphocytes,  453 
Lymphocytosis,  455,  464 
Lymphoma,  464 

M 

McBurney,  299 
McElroy,  346 
Mclvfinnon,  Jas.  F.,  68 
Mabbott,  96 
Alacewen's  sign,  559 
Malaria,  346 

definition,  346 
etiology,  347 
pathology,  354 
symptoms,  356 
treatment,  360 
and  anemia,  447 
blood  picture  in,  353 

hemoglobinuria,  358 
heredity,  353 
historical  note,  346 
prophylaxis,  359 
staining,  351 
susceptibility,  354 
in  typhoid  fever,  316 
Mai,  grand,  528 

petit,  528 
Malnutrition,  501 
Malt  soup,  138 
Malted  milk,  149 
Mania,  hysterical,  526 
Manson,  347 
Marasmus,  501 
Maseru,  368 
Mason,  369 
Masonic      Widows'      and      Orphans' 

Home,  60 
Mast  cells,  454 
Mastitis,  in  new-born,  47 
prognosis,  47 
symptoms,  47 
Miistoid  cells  at  birth,  18 
Mastoiditis,  185 
diagnosis,  185 
etiology,  185 
prognosis,  185 
symptoms,  185 
treatment,  180 
Masturbation  and  tliread  worms,  287 
Materna,  Hass,  603 
Maurer,  353 

Maxilla,  inferior  at  birth,  18 
Mays,  223 


672 


INDEX. 


Measles,  368 

buccal  eruption  of,  67 
complications  and  sequelae,   372 
definition,  368 
diagnosis,  373 
from  rubella,  373 
from  drug  eruptions,  374 
from  scarlatina,  374 
etiology,  368 
eruption,  370,  369 
prognosis,  373 
symptoms,  369 
synonyms,  368 
treatment,   374 
atypical  cases,  371 
German,  376 
malignant,  371 
quarantine,  427 
Measurements  chest  and  head,  55 
Meconium,  238 

differentiation  from  melena,  25 
passage  of,  in  asphyxia,  26 
Medicinal  antipyretics,  76 
Mega  colon,  288 
Megaloblasts,  453 
Megalocytes,  453 
Melena,  505 
Mellin's  food,  148,  149 
Meninges,  tuberculosis  of,  32 
tumors  of,  333 
diagnosis,  335 
etiology,  333 
pathology,  333 
prognosis,  335 
symptoms,   333 
treatment,  335 
Meningitis,    epidemic    cerebrospinal, 
518,  556 
bacteriology,  556 
diagnosis,  561 
etiology,  556 
•   pathology,  557 
prognosis,  557 
quarantine  in,  428 
symptoms,  557 
treatment,  561 
and  lobar  pneumonia,  222 
simple  acute,  555 
diagnosis,  556 
etiology,  555 
pathology,   555 
prognosis,  556 
symptoms,  555 
treatment,  556 
tubercular,  332 
diagnosis,  335 
etiology,  332 


Meningitis,  tubercular — contd. 
pathologj',  332 
prognosis,  335 
symptoms,  333 
treatment,  335 
Meningococcus,  557 
Menstruation,  60 

and  epistaxis,  155 
changes  in,  in  chlorosis,  459 
Mensuration,  73 
Methods  of  examination,  62 
Microblasts,  453,  456 
Micrococcus    lanceolatus,   433 
Microcytes,  453 
Microsporon  audonini,  580 
Microsporosa  trachomatorum,   191 
Middle  ear,  examination,  68 
Miliaria,  324,  576 

Milk,  analysis  of  different  animals, 
118 
analysis  of,  by  Babcock,  129 

by  Van  Slyke,   121 
bacteria  in,  101,  246 
bacterial  count.  105 
blue  discoloration,  105 
box  for  collecting  samples,   107 
breast,  90 

coming  of,  87 
composition  of,  91 
examination  of,  91 
too  small  amount  of,  91 
care  of  in  home,  114 

on  journey,  146 
casein,  119 

cause  of  epidemics,   112 
certified,   100,   104 

and  Kentucky  law,  102 
package,  104 
shiping  case,  106 
changes    in,    caused    by    bacteria, 

105 
clean  and  cold,  104 
combined   cows'   and   breast    feed- 
ing. 98,  99 
commissions,     American     Associa- 
tion :Medical  Milk,  100,  632 
Jefferson  county  Medical  .100 
Kentucky  law  regulating,  101 
New  Jersey  law,  100 
New  York".   100 
composition  of,  117 
condensed,  131 

analysis,  131.  132 
cause  of  rachitis,  507 
cow's,  100 

and  human,  comparative  analy- 
sis, 100,  132 


INDEX. 


673 


Milk,   cow's — contd. 

of  different  breed,  118 
one,   99 
diluents  in,  138 
diphtheria  due  to,   114 
and  distillery  waste,  108 
effect  of  heat  on,  117 
epidemics  due  to,  112 
fat  in,  120 

estimate  of,  129 
feeding,     symptoms     of     disagree- 
ment of,  144 
foreign  matter  in,  104 
heat,  effect  of,  117 
influience  of,  on   mortality   statis- 
tics, 115 
market,  108 
mothers'    and    cows'    comparative 

analysis,   100 
modifications,  598 

Babies'  Milk  Fund  Association. 

629 
Bauer's  formulae,  598 
Chapin  formulae,  025 
by  Deming  modifier,  604 
by  Hass  Materna,  603 
Connor's   tables,   002 
Hamilton's,  601 
Holt,  626 
Kerley,  628 
Ladd's  tables,  607 
Moffitt's  method,  015 
Sloane  maternitv  milk  set,  603. 

600 
Westcott's  formula-,  599,  601 
modified,  98,  125,  625 
laboratory,   125 
sugar  in,  131 
morbidity    and    mortality    statis- 
tics, influenced  by,  115 
mother's  supply  of,  97,  98 
pail,  hooded,  106 
pasteurization,  116 
peptonized,  133 
protein,  140 

salts,  inorganic,  in,  122 
s'^ore,  cards,   122 
set,  Holt's,  91 
slimy  and  ropy,   105 
sterilization,  116 
and  scarlet  fever,  113 
and  tuberculosis,  108 
and  tvphoid  fever,  113 
top,    i20 
Alitchell,  Weir,  521 
Mitral   regurgitation,    442 
pathology,  442 


Mitral    regurgitation — contd. 
physical  signs,  442 
prognosis,  443 
symptoms,  442 
stenosis,   443 
pathology,  442 
physical  signs,  443 
prognosis,  443 
symptoms,  443 
Modified  milk,   125 

prescription  blank,  125.  120 
Mohler,  109 
Moneorvo,  358 
Mongolian  idiocj',  473 
Monorchid,  24 
Morbilli,  368 
Morbus  maeulosis,  466 

ceruleus,  432 
Moro    reaction    in    tuberculosis,   341 
Morrow,  365 
Morse,  508,  515 
Mortality     statistics     influenced    by 

milk,  115 
Morton,  347 
Mosenthal,  400 
Moulding  of  head,   17 
Mouth,  breathing,  166 
care  of,  in  new-born,  31 
disease,  233 
examination,  67 
gonorrheal  infection,  239 
symptoms,  239 
treatment,  239 
ulceration  at  angles  of,  233 
Mother,   nursing,  89 
diet    of,    89 
milk  of,  87 
Muguet,  238 
]\lumps,   405 

Murphy's  saline  injection,  151 
Muscular  dystrophy,  progressive,  552 
etiology,  552 
pathology,  552 
prognosis,    554 
symptoms,  552 
treatment,  554 
Mustard  bath,  79 
plasters,  77,  81 
Muutermilch    fungus.    191 
Mya's  disease,  282 
Myelitis,  acute,  543 
diagnosis,  544 
etiology,  543 
patholog\',  543 
prognosis,  544 
symptoms,  543 
treatment,  544 


674 


INDEX. 


Myelocyte,  454 
Myocarditis,  acute,  449 

etiology,  449 

pathology,  449 

prognosis,  450 

symptoms,  450 

treatment,  450 
Myopathy  primary,  552 
Myopia,   187 
Myxedema,  473 

N 

Napkins,   care  of,   34 

rubber,  31 
Nasal  catarrh,   152 
polypi,  156 

symptoms,    156 
treatment,  156 
Nasopharynx  at  birth,  18 
Nauheim,  Schott  baths,  80 
Neck,  fistula  of,  242 
Neisser,  239 

Neonatorum  ophthalmia,   195 
Nephritis,     acute     parenchymatous, 
483 
complications  in,  485 
etiologj',  483 
pathology,  484 
prognosis,   485 
symptoms,  484 
treatment,  485 
diet,  485 
medicinal,  485 
management,  485 
prophylaxis,  485 
chronic  interstitial,  488 
etiology,  488 
pathology,  488 
prognosis,  488 
symptoms,  488 
treatment,  488 
chronic  parenchymatous,  486 
diagnosis,  487 
etiology,   486 
pathology,  486 
prognosis,  487 
symptoms,  486 
treatment,  487 
Nerves,  diseases  of  peripheral.  533 
Nervous  sj-stem,  diseases  of,  513 
diseases,  organic,  533 
diagnostic  methods  in,  513 
functional  disorders,  513 
Nestle's  Food,  149 
Nettle  rash,  596 
Neucleoalbumin  in  urine,  477 
Neuritis,  multiple,  533 
etiology,   533 


Neuritis — contd. 

pathology,  533 

prognosis,  534 

symptoms,  533 

treatment,  534 
Neusholme,   115 
New-born,  25 

atelectasis  in,  44 

bathing,  31 

care  of,  28 

diseases  of,  36 

dressing  of,  32 

examination  of,  30 

hair  of,  35 

hemorrhage  of,  38 

icterus  in,  44 

injuries  of,  36,  47 

mastitis   in,   45 

sepsis  of,  45 

skin  of,  35 

starvation  temperature  in.  4!) 

temperature  of,  35 

umbilical  hernia,  20,  42 

urine  of,  35 
Newman,  112 

New  York  Infant  Asylum,  500 
Nipple,  care  of,  87,  88,  123 
cracked  or  eroded,  87 
Mabbott's   treatment,   96 
shield,    87 

training  of  depressed,   87 
Nodules,    subcutaneous,    in    rheuma- 
tism, 322 
Noma,  236 
Normoblasts,  453 
Nose  at  birth,   18 

diseases  of,  152 

examination  of,  69 

foreign  bodies  in,  53 

irrigation  of,  82 
Nott,  347 
Nurse,  wet,  98 
Nursery,  34 

air  space  of,  19 

scales,  54 

temperature  of,  34 
Nursing,  bottles,  123 
contraindications  to.  88 
interval  at  birth,  87 
method  of.  90 
mother.  89 

bowels  of,  90 

diet  of,  89 

schedule  of,  88 
Nutritional   disorders.  501 

O 
Oatmeiil    jelly,    143 


INDEX. 


675 


O'Dwyef,  Jos.,   167,  422 

intubation  set,  423 
Olein  in  milk,   120 
Oliver's  hemoglobinometer,  452 
Ophthalmia  neonatorum,   195 
etiology,   195 
case   of,    196 

focal   symptoms,    19f 
prognosis,   196 
prophylaxis,  195 
sequelae.  195 
treatment,  196 
Ophthalmic  test  in  tuberculosis,  339 
Oppenheim,  549 
Optic  neuritis,  571 
Osttomvelitis     following     tonsilitis. 
160 
diagnosed  from  rheum;,  ..ism,  324 
Otitis  media,  in  typhoid  lever,  312 
acute  catarrhal,   177 
etiology,  177 
pa:hology,    177 
prognosiis,  178 
symptoms,  177 
treatment,  178 
acute  suppurative,  179 
etiology,   179 
prognosis,   182 
.  symptoms,   181 
treatment,    182 
differential  diagnosis  of,  183 
in  measles,  372 
in    scarlatina,   382 
temperature  curve  of,  180 
Outfit  for  baby,  18 
Ovaries  at  birth,  24 
Oxyuris  vermicularis,  287 
description,  287 
diagnosis,  288 
eggs  of,  288 
symptoms,  288 
treatment,  288  ■ 
Ozena,  154 

P 
Pack,  wet  cool,  80 
Palmitin  in  milk,  120 
Palpation,  69 
Palsies,  cerebral,  569 
diagnosis,  568 
etiology,  567 
pathology,  568 
prognosis,  568 
symptoms,  568 
treatment.  569 
Palsy,   Bell's   534 
facial,  534 
diagnosis,  535 


Palsy,  facial — contd. 
etiology,  534 
prognosis,  535 
symptoms,  535 
treatment,  535 
Paludism,  346 
Pannus  of  cornea,  191 
Paquelin    cautery    in    car.c    m   oris, 

237 
Paracasein  calcium,  119 
Paracentesis  of  drum,  176,  179 
Paraphimosis,  493 
treatment,  493 
Paraplegia,  spastic,  567 

in  syphilis  of  cord,  548 
Paralysis,  hereditary,  spastic,  551 
cerebral   type,   551 
cerebrospinal  type,  552 
diagnosis,  552 
prognosis,   552 
treatment,   552 
Erb's,  535 

prognosis,  535 
treatment,  535 
infantile,  536 
obstetrical,   535 
spinal  type,  551 
diagnosis,  552 
prognosis,  552 
treatment,  552 
Parasites,  benign  tertian  of  malaria, 
350 
estivoautumnal,  of  malaria,  351 
intestinal,   287 
varieties,  287 
quartan  of  malaria,  350 
Parasitic  skin  lesions,  576 
Park,  351 
Parker,  412 
Parotitis,  405 

complications,  406 
etiology,  405 
prognosis,  406 
quarantine  in,  429 
symptoms,  406 
treatment  of,  406 
Pasteurization  of  milk,  116 
Pasteurized   milk,  bacteria   in,    116 
Patterns  for  baby's  clothes,  33 
Pavor  nocturnus,  532 
Peabody,  536 
Pediculosis,  576 
capitis,  576 
diagnosis,  577 
treatment,  577 
corporis,    577 
diagnosis,  578 


676 


INDEX. 


Pediculosis,   corporis — contd. 

treatment,  577 
pubis,  578 
Peliosis  rheuniatica,  324 
Pellagra,  343 

diagnosis,  345 

etiology,  343 

pathologj',  345 

prognosis,  346 

symptoms,  344 

treatment,  346 
P<^mpliigus  vulgaris,  acute,  586 

diagnosis,  587 

etiology,  586 

pathology,  586 

symptoms,  587 

treatment,  587 
chart  of,  589 
foliaceous,   586 
neonatorum,  587 
vegetans,  586 
Peptogenic  mill;  powder,  148,  149 
Peptonized  millc,   133 
Percentage  system  of  feeding,  125 
Percussion,  72 
hammer,  73 
Perforation  in  typhoid  fever,  312 
Pericarditis,  433 

diagnosis,  435 

etiologj',  433 

forms,  433 

pathology,  434 

physical  signs,  434 

prognosis,  435 

symptoms,  434 

treatment,  435 
chronic,  437 

etiology,  437 

pathology,  437 

symptoms,  437 

treatment,  437 
fibrinous,  433 
forms  of,  433 
plastic,   433 
with  effusion,  435 

pathology,    436 

prognosis,  436 

symptoms,  435 

treatment,  436 
Perinephritis,  482 

definition,  482 

diagnosis,  483 

etiology,  482 

pathologj',   482 

symptoms,  483 

treatment,  483 
Peritonitis,  tubercular,  336 


Peritonitis,    tubercular — contd. 

pathology,  33{i 

symptoms,  336 

treatment,  336 
Peritonsillar   abscess,    164 

etiology,   164 

prognosis,  164 

symptoms,    164 

treatment,  164 
Perleche,  233 

etiology,  233 

symptoms,  233 

treatment,  233 
Pertussis,  399 

complications.  400 

diagnosis,  400 

etiology,   399 

Kilmer's  belt  in,  404 

pathology,400 

prognosis,  403 

quarantine  in,  403,  428 

symptoms,  400 

treatment,  403 
Peters,  353 
Peterson,  569 
Pfeiffer,  95 
Pfeiffer,  bacillus,  407 
Pharyngitis,  in  measles,  365 
Phenolphthalein,    281 

and  breast  mill:,  90,   108 
Phimosis,  492 

symptoms,  493 

treatment,  493 
Phlyctenular  keratitis,  198 

etiology,  198 

symptoms,  198 

treatment,  198 
Pills,   74 
Pin  worm,  287 
Pioscope,  94 
Plasmodium  malariie,  347 

vivax,  350 
Pleurisy,  224 
diagnosis,  226 

from  appendicitis,  300 

from  pneumonia,  222 
etiology,    224 
pathology.  225 
physical  signs.  213 
prognosis,  227 
symptoms,  225 
treatment,  227 
Pneumococcus,   in   tonsillitis.    159 
Pneumohydrothorax,   73 
Pneumonia,  broncho-,  212 

diagnosis,  215 

etiology,  212 


INDEX. 


677 


Pneiiinonia,    broncho — contd. 

pathology,   212 

physical  signs,  213 

prognosis,  216 

syniptoijis,  213 

treatment,   216 
croupous,  218 

differential     diagnosis,     from    ap- 
pendicitis, 300 
fibrinous,  218 
lobar,  218 

diagnosis,    222 

etiology,  218 

pathology,  218 

physical  signs,  220 

prognosis,  222 

symptoms,  218 

termination,   220 

treatment,  222 
and  measles,  372 
pleuro-,  221 
Poikilocytes,  453 
Poikilycytosis,  455 
Poliomyelitis  anterior  acuta,  536 

diagnosis.  541 

epidemiology,  537 

etiology,  537 

history,  536 

paralysis,  540 

jiathology,  538 

prognosis,  541 

symptoms,   538 

treatment,  542 
Politzer  bag,  176 
Politzeration,  176 

Polymorphonuclear  neutrophilic  leu- 
cocytes, 453 
Polypi,  nasal,  156 

symptoms,    156 

treatment,  156 
and  chronic  rhinitis,  156 
Pott's  disease,  70.  545 

diagnosis,  546 

prognosis,  546 

symptoms,  546 

treatment,  546 

X-ray  of,  546 
Powders,   74 
Poynton,  145,  437,  439 
Prepuce  at  birth.  23 
Prescription  blank  for  modified  milk, 

125,  126 
Presystolic  thrill,  443 
Progress  report,  56 
Proprietary  foods,   148 
Proteid  disagreement  in  breast  milk, 
79 


Proteid — contd. 

increase  of,  in  breast  feeding,  98 
of  milk,  chemistry  of,  119 
quotient,   119 

too  much,  in  milk  feeding,  144 
Pruritus,  595 

treatment,  595 
ani,  595 

in  diabetes  mellitus,  327 
Pseudohypertrophy   of   muscles,   552 
Pseudoleukemia,  464 
definition,  464 
diagnosis,  464 
pathology,  464 
prognosis,  464 
symptoms,  464 
treatment,  464 
infantum,    464 
definition,  465 
etiology,  465 
pathology,  465 
symptoms,  465 
treatment,  465 
Pseudopernicious  anemia,  464 
Psoriasis,  597 
Pterygium,  197 
etiology,   198 
syiriptoms,  198 
treatment,   199 
Pulmonary  collapse,  203 

lesions,  in  rheumatism,  324 
Pulmotor   in  asphyxia  of  new-born, 

28 
Pulse,  Corrigan's  444 
water  hammer,  444 
Purpura,   465 

etiology,  465 
pathology,  466 
symptoms,  466 
treatment,    467 
fulminans,  466 
hemorrhagica,  466 

in  rheumatism,  324 
Henoch's,    466 
rheumatica,  467 
simplex,    466 
symptoms,  466 
Pyelitis,  479 

definition,  479 

diagnosis,  480 

etiology,   479 

prognosis,  481 

symptoms,  480 

treatment,   4'81 

in  typhoid  fever.  311 

Pyelonephritis,  479 

Pyer's  patches,  308 


678 


INDEX. 


Pylorus,  stenosis  of  243 

diagnosis,  244 

pathology,  243 

symptoms,  243 

treatment,  244 
Pyonephrosis,  479 
Pyopericardium.    437 

etiology,  437 

pathology,  437 

prognosis,  438 

symptoms,  438 

treatment,  438 

Q 

Quarantine    in    contagious    diseases, 

426 
Quartan  parasite,  malaria,  353 
Quassia     in     treatment     of     thread 

worms,   287 
Quinsy,  164,  418 

R 

Rachitis,  507 

diagnosis,  511 

from    chronic    hydrocephalus, 

567 
from  rheumatism,  324 
from  syphilis,  365 
etiology,  507 
pathology,  508 
prognosis,    olO 
symptoms,  509 
focal,  50y 
systemic,  510 
treatment,  511 
medicinal,  511 
and  adenoids,   165 
and  chronic  rhinitis,  153 
Ralfe,  257 
Kamogen,  135,  149 

analysis  of,   136 
Ranula,  240 

symptoms,  240 
treatment,  240 
Rectal  feeding,  150 
Regions  of  chest,  62,  63 
Renal  calculus.  481 
etiology,  481 
symptoms,  481 
treatment,  482 
colic  in  calculus.  482 
decapsulation,  487 
Refrigerator,  Hess,  631 
Regurgitation,  442 
aortic,  444 
mitral,  442 
tricuspid,   446 


Rennet,  liquid,  134 
Report  of  infants'  progress,  56 
Respirations  in  new-born.  25 
Respiratory  organs,  disorders  of,  200 
■    foreign  bodies  in,  208 

diagnosis,   200 

symptoms,   200 

treatment,  201 
Retropharyngeal  abscess,   164 
Reynolds'  test  for  acetone,  258 
Rhagades.   364 
Rheumatism,  322 

complications,  323 

diagnosis,  324 

from  scorbutus,   324 

duration,  323 

etiology,  322 

pathology,  322 
.  prognosis,   325 

quarantine,  427 

symptoms,  322 

treatment,   325 
chorea  in,  323 

as  cause  of  heart  disease,  431 
skin  lesions  in,  324 
subcutaneous  nodules  in,  323 
tonsillitis  in,  323 
Rhinitis,  acute,   152 

diagnosis,  152 

etiologj',   152 

pathology,   152 

symptoms,  152 

treatment,  163 
atropic,   154 

etiology,    154 

prognosis.  154 

symptoms,  154 

treatment,  154 
chronic,    153 
Kib  resection  in  empyema,  230 
Richardson,   301 
Rickets,  507 
Riga's  disease,  240 

symptoms,  241 
Ringworm,  580 
Ritter.   40 
Rivinian   gland,  240 
Roberts,  344 

Romanowsky's  stain,  351 
Ross,  347 
Rotch,  T.  M.,  39,  126,  128.  145,  367, 

436,  557 
Rotheln  376 

Rover.  B.  Franklin,  24,  560 
Rubber,  bath  tub,  78 

syringe,  75 
Rui)ella,   376 


INDEX, 


679 


Eubella — contd. 

complications,   378 

diagnosis,  378 

from  measles,  373 

etiology,  376 

prognosis,  378 

quarantine,  42.ci 

symptoms,  376 

treatment,  378 
Rubeola,  368 

S 

Saccharomyces  albicans,  238 
Sachs,  552 

sign  of  chorea,  65 
St.  Vitus'  dance,  520 
Salmon,  112 

Salts,  inorganic,  in  milk,  122 
Salvarsan,  367 
Sarcini   ventriculi,  246 
Sarcoma  of  kidney,  488 
Sarcoptes  scabies,  578 
Sattler's  double  coccus,  190 
Scabies,  578 

diagnosis,  579 

symptoms,  579 

treatment,  579 
Scales,  nursery,  54 
Scalp,  ringworm  of,  580 
Scarlatina,  378 

complications,  382 

diagnosis,  384 

etiology.   378 

prognosis,  384 

quarantine,  427 

symptoms,  379 

treatment,  384 
prophylactic,  384 
symptomatic,  386 
Scarlet    fever    epidemics    and    milk. 

113 
Schamberg,  597 
Schaudinn,  354 
Schonlein's  disease,  324,  467 
Schott,  Nauheim  baths,  80 
Schultz  treatment  of  asphyxia,  28 
Schwartz,  table  of  weights,  57 
Schwer,   330 
Scleredema,   51 

etiology,  51 

pathology,  51 

symptoms,  52 

treatment,  52 
Sclerema,  51 
Sclerosis  of  spinal  cord,  549 

diagnosis,  549 


Sclerosis  of  spinal  cord — contd. 

etiology,  549  • 

pathology,  549 

prognosis,  549 

symptoms,  549 

treatment,  549 
Scorbutus,  504 

diagnosis  from  rheumatism,  324 
Score  cards  for  dairies,  122 
Scraped  beef,  143 
Scrofulous  conjunctivitis,  193 
Scurvy,  324,  504 

diagnosis,  506 

etiology,  504 

pathology,   505 

prognosis,  506 

symptoms,  505 

treatment,  o06 
Scutulum  in  favus,  580 
Searcy,  343 
Seat  worm,  287 
Seibert,  A.,  82 

Seller's  solution,  153,  154,  161,  176 
Sepsis  of  new-born,  45 

etiology,  45 

symptoms,  46 

treatment,  46 
Sera,    animal,    in    hemorrhages,    41, 

468 
Serum  albumin,  477 
Shield,  nipple,  87 
Shiga  bacillus,  246 
Shingles,   594 

Sigmoid  flexure  at  birth,  20 
Silver    solution    in    ophthalmia    ne- 
onatorum,  195 
Sinapism,  mustard,  77,  81 

turpentine,  77 
Skin,  diseases  of,  575 
exd.mination,  b9 
lesions  in  rheumatism,  322 
of  new-born,  30,  35 
Sleep,  disorders  of,  531 
Sloane  milk  modifier,  606 
Smallpox,  394 
Smith,  J.  Lewis,  556 
Smith.  Letchworth,  619 
Smithbank,  112 
Snow,  304 
Snuffles,  152 
Snvder,  292 
Soda  bath,  79 
Soor,  238 
South  worth,  134 
Spastic  paralysis,  hereditary,  551 

paraplegia,  567 
Sphenoid  bone  at  birth,  18 


680 


INDEX. 


Sphincter   aui,  dilatation   of,   in  as- 

pl»yxia,  28 
Specula,  ear,  68 
Spina  bifida,    18 
Spinal  cord,  diseases  of,  536 
sclerosis    of,    549 

diagnosis,  550 

etiology,   549 

pathology,  549 

symptoms,  549 

treatment,  550 
syphilis  of,  548 

diagnosis,  548 

pathology,  548 

spastic  paraplegia  in,  548 

symptoms,  548 

treatment,  548 
tumors  of,   547 

diagnosis,  547 

prognosis,  548 

symptoms,  547 

treatment,  548 
Spirocheta,  363 
Spleen,  at  birth,  20 
Spotted  fever,  556 
Sprue,  31,  238 
Squires'  sign,  51o 
Staining  malaria  parasite,  351 
Stanton's  percussion  hammer,  73 
Staphj'lococcus  in  tonsillitis,  160 
Staphyloma,  anterior,   195 
Starch,  digestion,  as  shown  by  stools, 

138 
Starr,  537 

Starvation    temperature,    49 
Statistics,   mortality  and  morbidity 

influenced  by  milk,   115 
Status  lymphaticus,  469 
Stearin  in  milk,  120 
Steelyards  for  weighing,  41 
Stenosis  of  pylorus,  243 
Stephens,  349 
Sterilization  of  milk,  116 
Sternum  at  birth,  18 
Stethoscope,  70 
Still  born,  25 
Stimulants,  76 
Sioelker,  433 
Stomach,  at  birth,  20 
bacteria  in,  237 
diseases  of,  245 
washing,  82 

apparatus  for,  83 
Stomatitis,  234 
catarrhal,  234 

symptoms,   234 

treatment,  235 


Stomatitis — contd. 
gangrenous,  236 

etiology,  230 

patliology,  236 

prognosis,  237 

sj^mptoms,  236 

treatment,   237 
herpetic,  234,  235 

etiology,  235 

pathology,  235 

symptoms,  235 

treatment,  235 
■   parasitic,  238 
syphilitic,  239 
ulcerative,  234 

etiology,  235 

pathology,  235 

symptoms,  235 

treatment,  235 
Stone  in  kidney,  481 
Stools,  curds  in  144 

number  in  24  hours.  246 
Strawberry  tongue,  68,  380 
Strepto':*occus,  in  tonsillitis.   160 
Stridor,  congenital  laryngeal,  170 
Stye,   188 

Siiheutaneous    nodules    in    rheuma- 
tism, 322 
Sudani ina,  324,  576 

treatment.  576 
Sugar,  content  in  milk,  131 

too  much  in  milk  feeding,  144 

of  milk  solution  at  birth,  88 

solution,  131 
Summer  diarrhea,  263 
Suppositories,  75 
Suprarenal  glands  at  birth,  21 
Surgery  of  intestines,  296 
Sutures  at  birth,  17 
Sydenham,  347 

chorea,  520 
Sylvester  treatment  of  asphyxia,  27 
Symblepharon,  191 
Synechia,  anterior.   195 
Synovitis,  in  syphilis,  364 
Syphilis,  congenital,  365 

diagnosis,  365 

etiology,  361 

hereditaria  tarda.   365 

mode  of  transmission,  362 

pathologA',  363 

prognosis,  365 

symptoms,  364 

treatment,  366 

of   special    symptoms,   367 
and  anemia,  447 
of  mouth,  239 


INDEX. 


681 


Sypliilis — contd. 

of  spinal  cord,  548 
Syringe  for  enemata,  75 
glass,  82 

T 
Tabes  and   Freidreich's  disease,  550 
Tache  cerebrale  in   tuliercular  men- 
ingitis, 334 
Tachycardia,  449 
symptoms,  445) 
treatment,  449 
Talbot,  144 

Tallquist  hemoglobin  scale,  452 
Tampon,  in  otitis,  178 
Tape  for  mensuration,  73 
Tapeworm,  293 
Teetli,  teniporary  anfl  permanent,  58 

Hutchinson,  60,  365 
Temperature,  66 

chart  in  otitis  media,   180 
method  of  taking,  66 
of   new-born,    35 
starvation,  of  new-born,  49 
Temporal  bones  at  birth,  18 
Tenia,  293 

symptoms,  294 
treatment,  294 
medio'anellata,  294 
solium,  293,  294 
eggs  of,  293 
head  of,  293 
Testicles,  at  birth,  23  > 
operation    fol-,    499,   492 
undescended.  499 
Tetanus,  49 

etiology,   49 
pathologj',  50 
symptoms,  50 
treatment,  51 
Tliayer,  354 

Therapeutics   of   infancy   and   child- 
hood, 74 
Thermos   bottle   as   cause   of   illness 

from  changes  in  milK,  114 
Thorax  at  birth.   18 
Threadworms",   287 
Thrill,  presystolic,  443 
Throat  diseases  of,  152 

examination   of,  66 
Thrush.  31,  238 
etiology,  238 
symptoms,  238 
treatment,  238 
Thymus  gland,  469 
at  birth,  19 
enlarged,  469 

symptoms  of,  469 


Thyroid  myxedema,  475 
Tinea  circinata,  580 
pathology,  581 
symptoms,  580 
treatment,  581 
favosa,  583 
diagnosis,  584 
etiology,    583 
pathology,  584 
prognosis,  584 
symptoms,    584 
treatment,  584 
tonsurans,  582 
diagnosis,  582 
etiology,  581 
pathology,  581 
prognosis,  582 
symptoms,  582 
treatment,  582 
Tongue,  depressor,  68 
diseases  of,  233 
epithelial  desquamation,  233 
examination  of,  68 
geographical,   233 
of  scarlet  fever,  380 
strawberry,  68,  380 
tie,  240 

treatment,  240 
Top   milk,    method   of   modification, 

130 
Tonsillitis,  acute  catarrhal,  159 
etiology,    157 
])rognosis,   158 
symptoms,    157 
treatment,    158 
follicular,  159,  418 
complications,  160 
diagnosis,   160 
etiology,   159 
treatment,  160 
in  rheumatism,  323 
Tonsillectomy,   162 
Tonsillotome,  162 
Tonsillotomy,    162 
Tonsils,  chronically  enlarged,  161 
symptoms  of,  161 
diseases   of,    156 
Torti,   347 

Tothe's  diagnostic  measui-es,  516 
Townsend,  39,  41 
Trachea,  at  birth,   18 
Trachoma,   190 
etiology,   190 
patliology,    191 
prognosis,   191 
sequela-,  191 
symptoms,  191 


682 


ESTDEX. 


Trachoma — contd. 
treatment,  192 
roller  forceps  for,  191 
Transfusion   of   blood   in   pernicious 

anemia,  458 
Tricuspid   regurgitation,   446 
pathologj^  446 
physical  signs,  446 
prognosis,  446 
symptoms,  446 
stenosis,  446 
etiology,  447 
pathology,  447 
physical  signs,  447 
symptoms,  447 
Trismus  nascentium,  49 
Tubercle  bacillus,  bovine  and  human 

type,  116 
Tuberculin,  339 

test  for  cattle,  111 
Tulberculosis,  329 
chart  of.  333 

British  Royal  Commission  on,  109 
diagnosis,  338 

calmette  method,  339 
cutaneous  method,  340 
from  bronchopneumonia,  215 
from  pseudoleukemia,  464 
Moro  method,  341 
etiology,  329 
frequency  of,  330 
ophthalmic  test  of,  339 
pathology,  329 
percentage  of,  in  cows.  111 
port  of  entry,  330 
symptoms,  333 
and  cows,  110 
and  measles.  365 
and  milk,  109 
in  typhoid  fever,  315 
of  adrenal  glands,  472 
glands,  329 
intestines,  329 
kidney,  330 
lungs,  330 
meninges,  330 
prevention,  342 
transmission   of,   through   milk, 

cases,  109 
treatment,  342 
varieties,  331 
Tubes,  intubation,  423 
Tubotympanic,  catarrh,  175 

differential  diagnosis  of,  175 
etiology,  175 
pathology,  175 
prognosis,  176 


Tubotympanic — con  td. 

symptoms,  175 

treatment,   176 
Turbinates,  hypertrophied,  69 

hypertrophy  of,  in  rhinitis,  152 
Typhoid  fever,  307 

age,  307 

bacteriology,  308 

chart  of,  310 

complications,  312 

definitions,  307 

diagnosis,  314 

duration,  303 

etiology,  307 

incubation,  308 

pathologj',  308 

prognosis,  316 

symptoms,  308 

treatment.  316 
diet,  318 

management,  317 
prophylactic,  316 
stimulation,  319 
aphasia  in,  313 
appendicitis,  316 
bowels  in,  320 
chorea  in,  313 
convalescence,  321 

diet  in,  321 
Ehrlich's  reaction,  311,  314 
epidemics  and  milk,  113 
eruption  in,  311 
fever,  319 

periods  of,  309 
furunculosis  in,  314 
hemorrhage  in.  312,  321 
malaria  in,  316 
melancholia  in,  313 
otitis  media  in,  313 
perforation  in,  312 
pneumonia  in,  313 
pyelitis  in.  316 
tuberculosis,  315 
tvmpanites,  320 
Widal  test.  311,  314 

U 

Ulcerations  at  angle  of  nioutli.  233 
etiology',  233 
symptoms,  233 
treatment,  233 
Ulcerative  stomatitis.  235 
Umbilical  cord,  dressing  of,  29 
ligature  of,  28 
hemori-hage.  37 
hernia,  20,  42 


INDEX. 


683 


Umbilicus,  graniilating,  37 

treatment,  37 
Uncinaria  duodenalis,  291 
Urethra,  male,  at  birth,  21 
Urethritis,  495 
gonorrheal,  495 
diagnosis,  496 
symptoms,  496 
treatment,  496 
simple,  495 
treatment,  495 
Uric  acid,  476 
infarcts,  21 
Urinal,  Chapin,  476 
Urine,  the,  476 

collection  for  examination,  85,  476 
incontinence,  491 

in  pertussis,  399 
in  infants  and  children,  476 
in  pyelitis,  479 
of  new-born,  35 
Urticaria,  596 
etiology,  596 
pathology,  596 
prognosis.  596 
symptoms.  596 
treatment.  596 
factitata,  590 
in  rheumatism,  324 
in  vaccination,  394 
Icterus  at  birth,  24 
Uvulitis,  163 

symptoms,  163 
treatment,  163 


\'acciiiatioii.  comi)lieation.s,  393 

history.  391 

normal  course,  393 

symptoms,  393 

technic  of,  391 

virus,  selection  of,  392 
Vaccinia,  393 

complications,  393 

f'ourse.  394 

history,  391 

symptoms,  393 
Vail's  method   of   everting  the   lids, 

197 
Valvular  lesions,  combined,  447 

prognosis,  447 

treatment,  447 
of  heart,  congenital.  431,  432 
Van  Slyke,  119,  120,  133 
Vapor,  calomel,  inhalations,  76 
Vaporizer,  207 


Varcella,  389 

complications,  390 

diagnosis,  390 

etiology,  389 

gangrenosa,  390 

prognosis,  391 

quarantine,  428 

symptoms,  389 
systemic,  390 

treatment,  391 
Variola,  394 

complications,  397 

confluent,  396 

definition,  394 

diagnosis,  397 

eruption,  395 

etiologj',  395 

hemorrhagic,  396 

prognosis,  397 

quarantine,  427 

symptoms,  395 

treatment,  397 
prophylactic,  397 
Vernal  catarrh  of  conjunctiva,  192 
Vernix  caseosa,  30 
Version,  47 

Vertebral    caries    and    retropharyn- 
geal abscess,  164 
Viscera  malposition  of,  24 
Vision  in  nervous  diseases,  515 
Vissman,  Dr.  Louis,  112 
Vomiting,  cyclic,  256 
Von  Jaksch',  464 
Von  Noorden,  461 
Von  Pirquet.  339.  340,  421 
Vulvovaginitis,  496 

complications,  497 

etiology,  496 

prognosis,  497 

symptoms,  497 

treatment,  497 

W 

Walker-Gordon  Laboratory,  125,  128 
Wallace,  303 
Wangenbrand,  236 
Washing,  stomach.  82 
Wassermann  reaction,  362 
Water,  albumin.  141 

to  nursing  baby,  87 
Wasting  disease,  501 
Wax.    impacted,    in    auditorv    canal, 
174 
treatment,  174 
Weaning,  99 
Week's  bacillus,  189 


684 


INDEX. 


Weichselbaum,  556 

Weiglit,  tables  for  calculation,  55 

at  birth,  53 
Weil.  J:mile,  42 
Werlhoff's  disease,  466 
Werner,  F.  W.,  318 
Westcott's  chart  for  milk  modifica- 
tions, 599 
formulis    for    milk    modifications, 
598 
Wharton's  jelly,  28,  37 
Whey,  133 

cream  mixtures,  134,  609 

analysis  of,  134 
feeding,  133 
W'hitehall-Tatum  bottle,  124 
Whooping-cough,  399 
etiology,  399 
quarantine,  403,  428 
WMckman,  537 


Widal  reaction,  311,  314 
Wilcox,  327 
Williams,   41 
Wilson,  24 

Winckel's  disease,  39 
Winslow,  95 
Wolff-Eisner,  340,  341 
Wine  whey,   133 
Worm,  hook,  286 

pin,  287 

round,  289 

seat,  287 

tape,  293 

thread,  287 
Wright's   method   of    inoculation   in 
vulvovaginitis,  497 


Young's  rule  for  dosage,  74 


Date  Due 

' 

PRINTED  IN  U.S.A.               CAT.    NO.    24    161                  S8 

UC  SOUTHERN  REGIONAL  LIBRARY  FACILITY 


A     000  416  965     2 


00 


Ul 

WSIOO 

c  * 

^^ 

T917d 
1913 

Tuley,  Henry  E 

2: 

Diseases  of  children. 

IBRARY 
HIC  PHYSICIA 

WSlOO 
T917d 
1913 
Toley,  Henry  E 

Dise 

ases  of  children. 

5 

MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


CO 


cs 


